Here's an update on smart pumps
and meds admin safety via the Premier GPO and their Safety News for
. A nice review of recently published research is provided,
with links to abstracts and downloads. The message once again is to pay
attention to the big picture; there's more to meaningful meds safety
improvements than buying a bunch of pumps and a server. Research has
demonstrated real value:

Preliminary data indicated an estimated 849 annual programming changes
("near misses"), i.e., potential infusion errors were averted by the
new system. The authors provide an example of the four-fold reduction
in the risk priority score of the FMEA (failure mode and effects
analysis) related to setting IV heparin infusion (from 210 to 56) after
implementation of the IV safety system. The system also provided
continuous quality improvement data for best practice improvement. For
example, identification of the peak times for error warnings occurred
between 3 p.m. and 9 p.m., prompting a review of workload and staffing

Because IV administration errors can originate in any phases of the
medication process such as prescribing, dispensing, patient
identification, pump programming, or documentation, there needs to be a
seamless interface of "smart" IV pumps with other technology designed
to reduce MEs.

Another key to improving effectiveness is incorporating IV pump smarts
into more of the clinical workflow. Pump vendors are quickly moving
past annonymous QA databases to patient and user identifiable clinical
transactions. Add alarm notification, which Cardinal's Alaris and
Baxter are providing, with ADT, order entry, and automatic
documentation into the EMR and you've got a closed loop system for
maximum patient safety.

Included are links to Insights from the sharp end of intravenous medications errors: implications for infusion pump technology (full text), in the journal QSHC, and Scanning out medication errors, published in the Pittsburg Business Times.