Integrated Solution Helps Improve Pediatric Patient Safety, Streamline IV Medication Management
March/April 2013
Integrated Solution Helps Improve Pediatric Patient Safety, Streamline IV Medication Management
Among the most common and dangerous types of medication error are errors made in administering medications intravenously—especially when the patient is a child.
Many of today’s patients in children’s hospitals receive medications via intravenous (IV) pumps rather than by oral or intramuscular routes. However, studies show that more than half of all serious medication errors among pediatric hospital patients occur when drugs are delivered intravenously. In fact, IV infusion medications are twice as likely to cause harm than manual medication administration (Ross et al., 2000; Kaushal et al., 2001; Institute of Medicine, 2007; ASHP, 2008). The error is most often due to how the medication is administered (Leape et al., 1995), and for children—much more so than with adult patients—the dosage and timing of the medication must be calibrated precisely using calculations largely based on the patient’s weight.
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How the Closed-Loop Model Works After a physician orders a drug, a pharmacist verifies the order to ensure appropriateness and then sends the order to the patient’s EMR. When the medication is due, the nurse scans the patient’s armband to verify identity and the drug label to verify that it’s the right medication, time, dose and route, as shown on the order in the EMR. For infusions, the nurse scans a barcode on the smart pump, triggering a wireless transmission of the physician’s order from the patient’s EMR to preprogram the pump. The nurse verifies the information on the smart pump, accepts the data, and the infusion begins. The infused volume of medication and other data are wirelessly sent back to the patient’s EMR from the smart pump for the nurse to review and accept into the EMR. |
This was the situation several years ago at Children’s Hospitals and Clinics of Minnesota, where IV infusions accounted for 65% of the medications administered, and about 49% of reported adverse drug events were related to medication administration of these infusions.
Innovative Approach Dramatically Cuts the Potential for Errors
To significantly improve the safety of IV infusion medications, Children’s of Minnesota became the first pediatric hospital to implement interoperability between infusion pumps and electronic medical records (EMR) in a closed-loop medication safety system developed in partnership with Cerner, an EMR company based in Kansas City, Missouri, and CareFusion, a maker of infusion smart pumps based in San Diego. Now, when a nurse scans the barcodes on the patient’s wristband, the medication label, and the infusion pump, the system wirelessly transmits the doctor’s medication order from the patient’s EMR directly to the smart pump to preprogram the infusion. Once the patient’s nurse reviews and confirms the programming, the medication is delivered intravenously to the patient. While this is not the first time barcodes have been used to match medications with patients, it is the first time they have been used to preprogram infusion smart pumps in a children’s hospital.
In 2012, Children’s completed a 6-week pilot study of the new system in its pediatric intensive care unit (PICU). The study showed that use of the closed-loop system for pills, shots, drops, and infusions sharply reduced Children’s medication errors—a decline of about 70% from a rate of seven errors per 10,000 doses, to two per 10,000 doses.*
For busy nurses, the new system eliminates the need to make dosing calculations at the bedside, program detailed information into the smart pumps, and manually enter the infusion data into the EMR. Instead, infusion data such as dose or rate changes are automatically sent to the EMR for the nurse to check and then electronically verify in the EMR to document the infusion. This is a dramatic improvement over the manual processes the hospital previously used. It also frees up nurses to spend more time at the bedside taking care of patients rather than making dosage calculations and manually documenting administration.
Another benefit of the new closed-loop system is that it ensures that clinicians have accurate data about the infusion and the patient’s response to the infusion. In critical care areas, large-screen computer monitors display infusion data alongside other patient data such as vital signs, heart rate, and blood pressure in a real-time visual graphic display, enabling clinicians to monitor the status of infusions from any location in the hospital for an individual patient or for an entire unit.
Children’s pilot study showed that over a 1-month period the closed-loop system triggered 234 “alerts” of a potential error out of more than 11,000 doses. “Potential errors” range from administering the medication more than 30 minutes too early or 30 minutes too late, to an absence of documentation, to the wrong dose or time for a medication. Although the vast majority of these potential errors wouldn’t have resulted in harm, this system put a powerful additional safety net in place, leveraging technological advances to back up Children’s staff and allowing for continuous quality improvement. For instance, the system’s data made it possible to report compliance rates for every nurse in the unit, enabling managers to identify staff members who need extra support and workflows that need tweaking. Moreover, under the old system, nurses had to constantly perform manual calculations, input information, and document their work in an environment that is busy and full of distractions. While the new system mostly catches minor errors, it has already helped avert potentially serious adverse drug events, and has clearly advanced patient safety and improved quality of care.
Enhancing Medication Management, Patient Safety, and Operational Efficiency
Like many hospitals, Children’s had historically supported safe medication administration through the manual practice of “Six Rights” of medication administration (deliver the right medication through the right route in the right dose to the right patient at the right time with the right documentation**). But when Children’s decided to add the safety net of an integrated system to the medication administration process, they wanted to include infusion medications as well. Children’s decided to participate in a development partnership with Cerner and CareFusion to develop the new system for pediatrics.
The partners decided to develop and test the new system in Children’s PICU because of that unit’s wide range of patients and the inclusion of infusion management (IM) technology. The goals for the pilot test were to introduce the technology and workflows into the clinical setting, validate technology and integration points, and confirm the education approach and effectiveness.
To develop this new system, project teams comprised of informaticists, clinical education specialists, pharmacists, information technology (IT)/clinical applications analysts, bio-medical staff, and vendor team members provided direction on implementation and support during rollout. The project started with a large organizational kick-off meeting to create organizational awareness and convey its importance of further improving patient safety and safe medication practices.
A major challenge was to achieve seamless integration between the prerequisite components of the new closed-loop system that included barcodes, wireless connectivity, provider medication order entry, an EMR, and smart infusion pumps. The objective was to ensure the system was developed for the nurses’ benefit, such as ease of use, intuitive commands, etc.—not for the ease of the IT department.
Onsite observation of clinical practice enabled informatics staff to understand clinical issues and workflow considerations. Nurse processes were mapped to ensure that the system would support all of the various medication-administration scenarios encountered in pediatric patient care, from small-volume syringes to large-volume infusions, as well as rapid dosing adjustments based on a patient’s condition.
Pharmacists also worked extensively with physicians to ensure that the orders would work with the automatic pump preprogramming function. Pharmacists conducted medication “scan fests” to validate that every medication could be scanned successfully.
During implementation, video and eLearning materials were used to take nurses through the conceptual process of using the new system. Hands-on experience was used in a train-the-trainer approach for clinical educators, patient care managers, patient care supervisors, and “super users” on individual nursing units.
To get ready to “go live,” unit-based super-users and clinical educators partnered with the project informatics nurses to provide staff education and ongoing support, while patient care managers helped the various units set expectations, prepare, and problem solve.
The Results
Children’s closed-loop medication delivery system has enhanced patient safety by adding an extra layer of safety, helping avert potential medication errors, and providing continuous quality improvement data. It improves the quality of patient care by fulfilling the Six Rights of medication administration, which are part of the system’s electronic checklist.
Since the successful conclusion of the pilot program, a number of positive developments have taken place that bode well for the expansion of this new closed-loop approach to delivering drugs to children in hospitals:
The pilot’s success in reducing errors and capturing “good catches” of potential errors is leading Children’s to continue rolling the program out to all units at both of its hospital campuses in Minnesota.
- Nurses at Children’s have positively adopted this technology, as indicated by compliance rates for scanning and barcode administration of 90% and higher (Table 1). Sharing compliance data transparently has also contributed to overall positive staff engagement and satisfaction.
- The new system was recognized in 2012 by the Minnesota Alliance for Patient Safety (MAPS) for a Process/System Innovation Award.
- Representatives from several other children’s hospitals have traveled to Minnesota to learn about the system.
- While Cerner is the first EMR vendor with the capability to develop this closed-loop system, other large EMR vendors are proceeding with development because of the promise it holds for patient safety.
- CareFusion continues to work with other hospitals to provide the safety benefits of a closed-loop system to safeguard IV infusions for adults as well as children.
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Table 1. Barcode Medication Administration (BCMA) Compliance Data
Following the ideal workflow is the safest for our patients! |
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Table 2. Programming Method for Smart-Pump Safety-Software-Protected Infusions
Safety Gains:
Auto-ID is an earlier technology that uses barcode scanning of the medication label (not the physician’s order) to pre-program the pump. |
In today’s evolving healthcare environment, hospitals are always looking for ways to effectively integrate health IT and medical devices into their best practices in order to enhance patient safety, improve the quality of care, and use resources efficiently.
Children’s closed-loop medication administration system is unique in that it enhances patient safety by extending barcoding a step beyond scanning shots, drops, and pills to using the EMR to preprogram infusion smart pumps in pediatrics. This replaces and dramatically improves on the existing manual processes, freeing the nurse to spend more time at the bedside to focus on the patient instead of making dosage calculations and documenting administration. Because this program safeguards virtually all medications, it is truly a first-of-its-kind in the pediatric setting.
Perhaps most significant? The added safety and efficiency of the new system affords nurses more time to do what is most satisfying and important—care for patients.
** These Six Rights are part of the closed-loop system’s electronic checklist.
Bobbie Carroll is senior director of patient safety and informatics at Children’s Hospitals and Clinics of Minnesota, where she has worked for the past 10 years. She is a registered nurse with a special interest in the adaptation of information technology to healthcare. She has been a vital contributor to the implementation of the electronic medical record at Children’s and has recently taken on the additional role of director of safety. Bobbie provides leadership in strategic development of technology to support patient safety, clinical practice, and process while assuring consistency with professional standards. She may be contacted at bobbie.carroll@childrensmn.org.
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