Adverse drug events are a significant concern in all healthcare settings. The risks increase when using injectable medications. Approximately 1.2 million hospitalized patients experience a preventable adverse event associated with injectable medications each year (costing each hospital an average of $600,000 extra per year).¹

Healthcare facilities are increasing their reliance on smart infusion pumps to help reduce adverse drug events. However, smart infusion pumps don’t come without risk. In one new study of smart pumps, we learned that delays in updating smart pump drug libraries poses a significant patient safety risk.² The study found that when new drug library versions are released, significant delays can occur before all pump libraries are updated. The delays in drug library updates led to false alerts and missed infusions of high-risk medications.

Since 2012, Oregon’s Patient Safety Reporting Program (PSRP) has received numerous reports of adverse events involving infusion pumps. Adverse drug events have occurred in Oregon facilities because:

• The pump did not contain the appropriate drug library (e.g., NICU, pediatric, adult)

• The drug library had not been installed on the pump

• Staff didn’t understand how to program the pump or interpret confirmation screens

• Drug dose and rate were selected or entered into the pump incorrectly

What You Can Do

Facilities are implementing smart infusion pump technology to prevent adverse events from occurring during drug administration; however, safely implementing smart infusion pumps requires careful planning and ongoing auditing. In 2009, the Institute for Safe Medication Practices (ISMP) published its first Guidelines for Safe Implementation and Use of Smart Infusion Pumps. Now, a decade later, ISMP has drafted revised guidelines that will soon be finalized.

Your facility can use ISMP’s smart infusion pump guidelines to ensure processes and practices maximize patient safety. The guidelines address implementation, clinical practice, and drug libraries. For example, some of the ISMP recommendations for smart infusion pump drug library safety include:

• Only use smart infusion pumps capable of wireless drug library updates, data transmission, and bi-directional communication with the electronic health record (EHR).

• Require comprehensive, reliable wireless connectivity throughout the organization where smart pumps will be in use to update drug libraries, obtain system reports and data, and support bi-directional communication with the EHR.

• Use tracking technology to locate and manage smart pumps within the institution.

• Define the committee(s) or department(s) with ownership of smart pump system software, oversight of drug library revision requests, process decisions, protocol development, and pump maintenance.

• Allocate resources for ongoing maintenance of smart pump-related electronic databases/systems to provide standardization of infusion parameters and timely system updates to address drug shortages, new drugs added to the formulary, and development of new drug protocols.

Smart pumps can reduce the frequency of adverse drug events, but safe use requires continuous education, auditing, and refinement.³

What You’ll Need

Draft Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps
Institute for Safe Medication Practices
Stay tuned for new, finalized smart infusion pump guidelines from ISMP that are a comprehensive resource for optimizing smart infusion pump technology and interoperability in your facility.

What have you done to address this or similar safety risks? Share what you’ve learned in your organization and contribute to the ongoing learning about adverse events in Oregon through the Patient Safety Reporting Program.

References

¹ Lahue, B. J., Pyenson, B., Iwasaki, K., Blumen, H. E., Forray, S., & Rothschild, J. M. (2012). National burden of preventable adverse drug events associated with inpatient injectable medications: healthcare and medical professional liability costs. American health & drug benefits, 5(7), 1–10.

² Hsu, K., DeLaurentis, P., Bitan, Y., Degnan, D.D., Yih, Y. (2019). Unintended Patient Safety Risks Due to Wireless Smart Infusion Pump Library Update Delays. Journal of Patient Safety, 15(1), e8–e14.

³ Breland, B.D. (2010). Continuous Quality Improvement Using Intelligent Infusion Pump Data Analysis. American Journal of Health-System Pharmacy, 67(17), 1446–55.