Programmable Infusion Pumps in ICUs: An Analysis of Corresponding Adverse Drug Events

详细信息    查看全文

• 作者：Teryl K. Nuckols MD ; MSHS (1) (2)
  Anthony G. Bower PhD (1)
  Susan M. Paddock PhD (1)
  Lee H. Hilborne MD ; MPH (1) (3)
  Peggy Wallace RN ; MSN (1)
  Jeffrey M. Rothschild MD ; MPH (4)
  Anne Griffin RN ; MPH (1)
  Rollin J. Fairbanks MD ; MS (5)
  Beverly Carlson MS ; RN ; CNS (6)
  Robert J. Panzer MD (7)
  Robert H. Brook ScD ; MD (1) (2)
  
• 关键词：drug therapy ; medication error ; prevention and control ; infusion pump ; decision making ; computer ; assisted ; critical care
• 刊名：Journal of General Internal Medicine
• 出版年：2008
• 出版时间：January 2008
• 年：2008
• 卷：23
• 期：1-supp
• 页码：41-45
• 全文大小：111KB
• 参考文献：1. Rothschild JM, Landrigan CP, Cronin JW, et al. The critical care safety study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8):1694-00. CrossRef
  2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274(1):29-4. CrossRef
  3. Apkon M, Leonard J, Probst L, DeLizio L, Vitale R. Design of a safer approach to intravenous drug infusions: failure mode effects analysis. Qual Saf Health Care. 2004;13(4):265-1. CrossRef
  4. Alaris Medical Systems. Guardrails? suite of safety software for the Alaris system. Available at: http://www.cardinalhealth.com/alaris/products/Guardrails/. Accessed September 27, 2007.
  5. Fields M, Peterman J. Intravenous medication safety system averts high-risk medication errors and provides actionable data. Nurs Adm Q. 2005;29(1):78-7.
  6. Hatcher I, Sullivan M, Hutchinson J, Thurman S, Gaffney FA. An intravenous medication safety system: preventing high-risk medication errors at the point of care. J Nurs Adm. 2004;34(10):437-. CrossRef
  7. Malashock CM, Shull SS, Gould DA. Effect of smart infusion pumps on medication errors related to infusion device programming. Hosp Pharm. 2004;39(5):460-.
  8. Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med. 2005;33(3):533-0. CrossRef
  9. Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care. 2003;12(3):194-00. CrossRef
  10. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981;30(2):239-5. CrossRef
  11. Dubois RW, Brook RH. Preventable deaths: who, how often, and why? Ann Intern Med. 1988;109(7):582-.
  12. Landis RJ, Koch GG. A one-way components of variance model for categorical data. Biometrics. 1977;33(4):671-. CrossRef
  13. Husch M, Sullivan C, Rooney D, et al. Insights from the sharp end of intravenous medication errors: implications for infusion pump technology. Qual Saf Health Care. 2005;14(2):80-. CrossRef
  14. Heinemann L, Anderson JH Jr. Measurement of insulin absorption and insulin action. Diabetes Technol Ther. 2004;6(5):698-18. CrossRef
  15. Gentilini A, Schaniel C, Morari M, Bieniok C, Wymann R, Schnider T. A new paradigm for the closed-loop intraoperative administration of analgesics in humans. IEEE Trans Biomed Eng. 2002;49(4):289-9. CrossRef
  16. Poon EG, Blumenthal D, Jaggi T, Honour MM, Bates DW, Kaushal R. Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. Health Aff (Millwood). 2004;23(4):184-0. CrossRef
  17. Wickens CD, Lee J, Liu Y, Becker SG. An Introduction to Human Factors Engineering. Saddle, NJ: Pearson/Prentice Hall; 2004:426.
  18. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197-03. CrossRef
  19. Morimoto T, Gandhi TK, Seger AC, Hsieh TC, Bates DW. Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care. 2004;13(4):306-4. CrossRef
  
• 作者单位：Teryl K. Nuckols MD, MSHS (1) (2)
  Anthony G. Bower PhD (1)
  Susan M. Paddock PhD (1)
  Lee H. Hilborne MD, MPH (1) (3)
  Peggy Wallace RN, MSN (1)
  Jeffrey M. Rothschild MD, MPH (4)
  Anne Griffin RN, MPH (1)
  Rollin J. Fairbanks MD, MS (5)
  Beverly Carlson MS, RN, CNS (6)
  Robert J. Panzer MD (7)
  Robert H. Brook ScD, MD (1) (2)
  
  1. The RAND Corporation, Santa Monica, CA, USA
  2. Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
  3. Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
  4. Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
  5. Department of Emergency Medicine, University of Rochester, Rochester, NY, USA
  6. Clinical Research Department, Sharp HealthCare, San Diego, CA, USA
  7. Department of Medicine, University of Rochester, Rochester, NY, USA
  

文摘

Background Patients in intensive care units (ICUs) frequently experience adverse drug events involving intravenous medications (IV-ADEs), which are often preventable. Objectives To determine how frequently preventable IV-ADEs in ICUs match the safety features of a programmable infusion pump with safety software (“smart pump- and to suggest potential improvements in smart-pump design. Design Using retrospective medical-record review, we examined preventable IV-ADEs in ICUs before and after 2 hospitals replaced conventional pumps with smart pumps. The smart pumps alerted users when programmed to deliver duplicate infusions or continuous-infusion doses outside hospital-defined ranges. Participants 4,604 critically ill adults at 1 academic and 1 nonacademic hospital. Measurements Preventable IV-ADEs matching smart-pump features and errors involved in preventable IV-ADEs. Results Of 100 preventable IV-ADEs identified, 4 involved errors matching smart-pump features. Two occurred before and 2 after smart-pump implementation. Overall, 29% of preventable IV-ADEs involved overdoses; 37%, failures to monitor for potential problems; and 45%, failures to intervene when problems appeared. Error descriptions suggested that expanding smart pumps-capabilities might enable them to prevent more IV-ADEs. Conclusion The smart pumps we evaluated are unlikely to reduce preventable IV-ADEs in ICUs because they address only 4% of them. Expanding smart-pump capabilities might prevent more IV-ADEs.