Although many of the events reported to the FDA were related to deficiencies in device design and engineering, user errors also occurred. One study found that almost half of all infusion-associated medication errors were attributed to deviations in following procedures and documentation requirements. 84 Intravenous (IV) infusions in particular pose risks to patient safety due to their complexity and the multiple steps required in their administration. Studies have found that IV infusion is associated with 54% of all adverse drug events, 56% of medication errors, and 61% of serious and life- threatening errors. 85 In addition, IV medications are twice as likely to be involved in errors that cause harms when compared to medications delivered via other routes. Smart infusion pumps have been implemented to avert possible medication errors; however, the risk of programming errors and equipment failures has not been eliminated. For example, one study found that despite use of smart pumps, 67% of the infusions evaluated involved one or more discrepancies. Studies have shown that infusion pumps can contribute to inefficiencies and lead to errors. This is largely due to time-consuming, indirect patient care tasks associated with infusion pumps, such as searching for available pumps, priming tubing, manual pump programming, responding to false or unnecessary pump alarms, and managing tangled tubing. Inadequate workflows for these tasks can impede communication and cause unnecessary rework, delays, or gaps in care, all which impact patient safety. Organizations must also consider how new technology, such as smart pumps, affects workflow and is best implemented in order to drive toward safer use processes. Successful implementation often requires organizational commitment, a shared vision, an understanding of the risks and strengths of current processes, and a unified design that includes all systems and stakeholders. Implementation Changing processes or redesigning workflows for infusion pumps can be a complex undertaking that includes a variety of interventions. Standardization and streamlining of processes and workflows were identified as main facilitators of optimal infusion pump use across multiple studies. For example, one study found that a hospital was able to significantly improve utilization of IV infusion pumps by streamlining its workflow for cleaning and restocking pumps. The implementation of smart pumps should be viewed as part of a larger safety initiative rather than just a technology upgrade and to be successful, implementation should focus on design of workflows. For example, implementing design- oriented solutions that constrain users to follow the preferred workflow, such as defaulting users into using the drug library, helps ensure users employ the safety features.
In addition, engaging multiple members of the care team in workflow redesign is an important facilitator. Clinical pharmacists play a key role in reducing error rates and should be consulted when configuring workflows. In some cases procedural deviations are not representative of inadequate care practices but rather demonstrate a poor fit between hospital policy and everyday practice. If workflows do not align with new technology or policies are implemented that are not compatible with natural workflows, then errors or workarounds can occur that impact patient safety. Staff buy-in and hospital resources can pose barriers to process changes. When implementing infusion pump technology, organizations need to ensure that adequate infrastructure and resources are available, and that the affected staff believe that the change is worth the time and money required. More implementation studies are needed to understand best practices for reducing errors and improving infusion pump use through workflow and process changes. Staff education and training The literature shows that inadequate training is often associated with knowledge and rule- based mistakes when using infusion pumps. These medication errors can occur when staff are inexperienced, including being unfamiliar with the medication, environment, procedure, or equipment. In addition, lack of training can lead to overriding of smart pump safety features erroneously. Although smart pumps can be a beneficial tool to reduce medication errors attributed to manual programming, using the embedded drug libraries and DERSs is not mandatory. The literature shows that nurses commonly bypass the safety features because the drug library parameters are not customized for their patient population, it takes too much time to program the pumps, and there are too many alarms. To prevent overriding safety features and programming errors, some hospitals invest in initial and ongoing staff training on the correct use, maintenance, and monitoring of smart pumps. Hospitals may also implement standard procedures for pump management and provide education on the use of the standardized protocols. The FDA recommends providing training and educational activities for all employees designed to promote the safe use of infusion pumps, including drug library usage, as a risk-reduction strategy for facility administrators and managers. In addition, organizations should establish a standard approach for staff training and ensure that the education provided emphasizes the intended safety benefits. Facilitators and barriers The type and content of education provided are important facilitators to successful implementation. For example, education from the device manufacturer alone may be insufficient and implementing a hands-on training targeting identified obstacles can be essential to increasing use of safety features.
In order to be most successful, the training program should include opportunities for participants to apply learning through discussing case examples. Training should also provide information about the most relevant smart pump functions and the potential challenges nurses may encounter in using them. Virtual training systems have been shown to facilitate learning, although the results are mixed. In addition to the type of training, the choice of trainer can be a facilitator. Implementing a nurse champion-led group may improve smart pump compliance, and training that focuses on “why” smart pumps are used instead of just “how” to use smart pumps is important to increase adherence. By understanding the safety software, nurses are able to provide ongoing evaluation on needed revisions and refinements. Limited knowledge transfer and constrained hospital and staff resources are potential barriers to implementation. For example, when nurses move to different wards, they are often exposed to new devices on which they have not been trained. In addition, after nurses are trained, they may not retain competency on use of a particular type of smart pump if they commonly use multiple types of pumps or if they infrequently use any pumps. Furthermore, establishing hospital-wide education programs can be a significant undertaking for staff development departments, and the time and energy constraints on nurse educators should be carefully considered and planned. Resistance to culture change is also a potential barrier. Despite being educated on the use of standardized pump programming, nurses may be resistant to a culture change from the old processes to a new two-person verification process. Implementing a nurse-led program focusing on promoting compliance, partnering with pharmacists, and supporting manual audits can help create a culture of safety. Conclusions Evidence shows that protocols and workflows are integral to proper technology use and therefore should be carefully considered when implementing new infusion pump technology. Studies support streamlining and standardizing workflows. However, more implementation studies are needed to better understand the impact of workflow changes and best practices for effective integration of processes and infusion pump use. The evidence also shows support for providing education and training on infusion pumps to promote safe use. In these studies, the type and content of education provided were highlighted as facilitators, while limited knowledge transfer and resistance to culture changes were identified as barriers. Carbapenem-resistant Enterobacteriaceae (CRE) CRE encompass a family of gram-negative bacteria that cause infections with high mortality rates and few therapeutic options due to their ability to confer resistance to many different antibiotics.
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