Download BC Cancer Agency - Quality Forum 2017

BC Cancer Agency
Dose Error Reduction Software:
Choosing the Least Risky
IV Pump
Sue Fuller Blamey & Karen Janes
Objectives
To review two dose error reduction
software (DERS) IV pump to identify failure
modes and mitigation strategies
 To choose the least risky intravenous pump
that includes the most effective mitigation
strategies to prevent IV errors

IV Pump Implementation Team
Team – Nurses, senior leaders, Quality
Director, pharmacists, physicians
 Human factors analysis
 Conducted Failure Modes Effects Analysis to
identify failures, mitigation strategies and
educational plans
 Staff IV Pump testing

Process Flow/Failure Modes:
Alaris and Hospira Pumps
Primary Channel: Programming set-up
Alaris IV Pump FMEA: Process Flow Diagram with Failure Modes
1. Priming IV Set
-Incorrect
techniques
-Selection of
wrong tubing or IV
set
9. Enter
Guardrails
-Select basic
infusion mode
(bypassed
guardrails)
16. Enter Rate
-Enter wrong rate
IV Smart Pump Dataset
Creation Process
DERS
1. Encounter Alert
-Receive no alert
for wrong dose
- Alert occurs for
correct dose
1. Profile
-Profile
architecture does
not represent
clinical needs
8. DERS device records
data
-DERS devices does not
record data
2. Load IV Set into
intended Channel
-Load set
improperly
causing free flow
error
-Load wrong
channel
10. Select Drug
-Select wrong
drug
17. Start Infusion
-Infusion fails to
start
2. User does not
proceed with a
clinically correct
dose
-Workarounds:
proceeding with
incorrect dose
2. Selects
medications and
fluids to be
included
-Missing
medications and
fluids in the
dataset needs for
clinical practice
(1500)
3. Turn Pump 0n
-Pump doesn’t go
on
11. Select
Concentration
4. Confirm
maintenance
reminder
-Failure to
acknowledge
reminder
12. Enter BSA
-Select wrong
concentration
-Wrong BSA is
entered
18. Infusion
Complete
-Infusion does not
infuse on intended
time
-Infusion does not
infuse at all
-Free flow
occurring to
patient
-Free flow occurs
on user
5. Confirm Patient
ID/ 6. Enter New
Patient ID
-Entering wrong
pt. name or
incomplete info
entered
13. Enter total
Dose
7. Want to use
same profile/
Select Profile
-Select wrong
profile
14. Enter volume
to be infused
-Enter wrong total
dose
-Entered wrong
volume too much
-Entered wrong
volume not
enough
5. Assigning
medications to the
profiles
-Medications and
fluids are located
in wrong profiles
-Concentrations
are located in the
wrong profiles
6. Set limits for
rate, flow and
concentration
-Limits conflict
with practice
-Missing limits
8. Select Channel
-Choose wrong
channel
15. Enter time
-Enter wrong time
19. Unload IV set
3. Proceed with
clinically correct
dose
-Not proceeding
with clinically
correct dose
3. Enter
nonmenclature of
medications and
fluids
-Missing
nonmenclature
-Nonmenclature is
not recognized by
the users
10. Analyzing and
interpreting your data
-Unable to analyze and
interpret the data
4. Enter
concentrations for
the medications
and fluids
-Too many
concentrations
-Missing
concentrations
-Wrong
concentration
entered
11. Change the Dataset
-Unable to change the
data set
-Change of the dataset is
wrong
7 and 9. Upload
and download
datasets to DERs
pumps
-Unable to upload
data through the
infrastructure
-Unable to upload
data in a timely
manner
Root Cause Analysis
Root Causes of Failures






DERS Opt in software – staff
have to go through multiple
steps to opt in
Enter wrong BSA calculation
Culture of staff overriding
safety steps
Lack of education
More than one type of pump
in use
Forgot to unclamp IV set
FMEA Worksheet Analysis
HFMEA Subprocess Step Title and Number
HFMEA Step 5 - Identify Actions
HFMEA Step 4 - Hazard Analysis
Proceed?
Detectability
Existing Control
Measure ?
Single Point
Weakness?
Decision Tree Analysis
Haz Score
Potential Causes
Severity
Failure Mode: First
Evaluate failure
mode before
determining
potential causes
Probability
Scoring
Action Type
(Control,
Accept,
Eliminate)
Actions or Rationale for
Stopping
Outco
Meas
User does not know
correct method
uncommon
1
Moderate
1.1 Incorrect techniques
More formal IV pump
education
4
Y
Y
N
Y
C
List of st
attending
educatio
Comparing Risk
Risk
Alaris
Hospira
1. DERS
Software
Entry/Exit
Higher risk of non- Opt-out can occur
compliance
but is not the path
of least resistance
2. New Patient
Selection
Risk of BSA userbased errors
Low risk with tight
DERS limits
3. Loading of IV
tubing
Potential for
slowed incorrect
rate
No risk
Comparing Risk
Risk
Alaris
4. BSA
Calculator
No risk – no BSA
calculator
5. Syringe Pump
Accuracy
+/- 2%
6. Server
1 connectivity
licence per pump
is required to
connect to
external server
Hospira
Potential for risk
of user-based
BSA errors
+/- 5% (no
paediatrics for
BCCA)
Server sits within
PHSA domain
Comparing Risk
Risk
7. Wireless
8. Clinical
simulation with
nurses
9. Ergonomic
Alaris
Hospira
Issues with PHSA Server sits within
security network
the PHSA network
domain
More difficult to
Easier to prime
operate
tubing, more user
friendly and
intuitive
Push button/touch
Difficult to open
and close
screen operated
Automatic loading
Manual loading
Comparing Risk
Risk
10. Risk of
repetitive strain
injury (RSI)
Overall risk
Alaris
Standard release
system – at risk
for RSI
Higher risk
Hospira
Release system
potentially
reduces RSI
Lower risk
Decision-making criteria – Hierarchy
of Effectiveness in preventing errors
Hierarchy of Effectiveness
of Interventions
1. Forced functions and constraints
2. Automation/computerization
3. Simplification/standardization
4. Reminders, checklist, double-checks
5. Rules and policies
6. Education and information
Decision-making Criteria
Forced functions of DERS Opt out
technology forces staff to use DERS
unless they go through multiple steps
 Implemented a function where nurses
have to formally request the Opt out in
order to not use DERS

Results: 97.7% compliance with DERS
software from implementation date

Questions