The New Normal:
Sustaining Medication Safety Gains with
Infusion Pump Programming
Bobbie Carroll, RN, MHA Sr. Director of Patient Safety & Informatics
Sarah Giga, MS, Manager, Clinical Integration
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Children’s Hospitals and Clinics of
Minnesota
Our volumes:
Supporting the kids:
• 12,586 inpatient admissions
• 381 beds in 2 cities
• 19,577 surgical cases
• 4,526 employees
• 90,673 emergency room visits
• 1,731 professional staff
• 259,118 outpatient clinic visits
• Visionary Board of Directors
• $650M+ annual revenue
Reducing Medication Errors
Children’s has implemented several process improvement initiatives
and technologies to reduce adverse drug events over the past
several years.
• Smart Pump infusion system designed to achieve safety benefits
through ‘guard rails’ utilization
• Computerized provider order entry (CPOE) designed to minimize
transcription and legibility errors, plus offer standardized evidence
based order sets
Smart Pumps – Phase One
CareFusion
Smart Pumps
implemented with
Guardrails
5/2005
9/2005
CareFusion
Auto-ID at
the pump
8/2007
BCMA, Smart Pump
programming, Infusion
management (PICU
pilot)
3/2012
10/2010
ePrescribe
5/2009
9/2006
Cerner CPOE
Cerner nursing
documentation –
iView, eMAR , I&O,
3/2010
PowerForms, PAL
Cerner iAware
for Critical Care
2012
BCMA, SPP,
IM - Inpatient
2013
BCMA, SPP, IM –
ED, Clinics,
Surgery
Why Smart Pumps?
• Benefits
– Dose Error Reduction Software (DERS)
• Drug dose range checking
• Concentration checking
– Single programming interface
• Modular design
– Limit drugs based on profile
• Started with 4 profiles: NICU PICU, Med/Surg, Hem/Onc
– Continuous Quality Improvement (CQI) data
Smart Pumps – Phase Two
CareFusion
Smart Pumps
implemented with
Guardrails
5/2005
9/2005
EasyScript
BCMA, Smart Pump
programming, Infusion
management (PICU
pilot)
3/2012
CareFusion
Auto-ID at
the pump
8/2007
5/2009
Cerner CPOE
9/2006
Cerner nursing
documentation –
iView, eMAR , I&O,
PowerForms, PAL
10/2010
ePrescribe
3/2010
Cerner iAware
for Critical Care
2012
BCMA, SPP,
IM - Inpatient
2013
BCMA, SPP, IM –
ED, Clinics,
Surgery
Auto-ID module
Shared Across All Infusion Types
• Pre-programs elements on the pump, based on label
produced when medication is dispensed from Pharmacy
Smart Pumps – Phase Three
CareFusion
Smart Pumps
implemented with
Guardrails
5/2005
9/2005
EasyScript
BCMA, Smart Pump
programming,
Infusion management
(PICU pilot)
3/2012
CareFusion
Auto-ID at
the pump
8/2007
5/2009
Cerner CPOE
9/2006
Cerner nursing
documentation –
iView, eMAR , I&O,
PowerForms, PAL
10/2010
ePrescribe
3/2010
Cerner iAware
for Critical Care
2012
BCMA, SPP,
IM - Inpatient
2013
BCMA, SPP, IM –
ED, Clinics,
Surgery
Development Partnership
Solution Partnership for Smart Pump Programming and Infusion
Management
• Joint effort to develop integration between Cerner EMR and
CareFusion Alaris Smart Pump
• First pediatric hospital to implement world wide and the most
advanced utilization (2012)
EMR
Device
EMR Integration
Ideal End State - IV Medication Flow
1.Scan the patient
2. Verify correct patient
8. Review results in
viewer (iAware)and
send to EMR***
3. Scan medication
6-rights plus:
Auto program the pump
with order detail
7. Verify correct
programming of
pump
Auto download infusion
volumes into EMR***
6.Scan channel
5. Document medication
*** critical care units only
10
4. Verify correct med,
time, dose, route
Rollout Status – Complete!
Inpatient
Live
Beds
BCMA
Smart Pump
programming
Infusion
Management
Critical Care
156
X
X
X
Medical/Surgical
225
X
X
381
Unit Type
Live
Beds
BCMA
Smart Pump
programming
Emergency Dept
N/A
X
X
Preop/PACU
N/A
X
X
Short Stay
N/A
X
X
Radiology
N/A
X
Hem/Onc clinic/Infusion
Center
N/A
X
X
Infusion
Management
Are we providing safer care?
• Safety learning reports related to medication administration events
have decreased by ~ 37%
• Staff nurses report situations where BCMA prevented a medication
error
• Patient satisfaction data shows a sustained improvement in parent
confirmation of patient identification before medication administration
• Data shows on average a 57% increase in smart pump drug safety
parameters utilization since implementation and is sustaining
BCMA Compliance Data
95.5
95
January 2013 – June 2014
94.5
94
93.5
93
92.5
92
91.5
91
90.5
• Following the ideal workflow is the safest for our patients!
• Organizational goal = 90%
Smart Pump Programming Utilization
• Report generation
– Report from EMR
– Denominator starts with all medication orders with a route=IV
• Not all are administered on the infusion pumps
– Exclusions identified: PCA, code situations, push
meds (things with a duration less than 5 minutes),
medications not in Guardrails yet
– Method to exclude: List of medications/form/dates to
remove from denominator
» List continues to be refined based on
data/examples
Inpatient Smart Pump Programming
Compliance: July 2014
• SPP successful % excludes medications that shouldn’t be smart
pump programmed (e.g. patient-controlled analgesia, push
medications, etc.)
Smart Pump Safety Software Utilization
• Guardrails = the Smart Pump software that allows the creation of a
drug library that includes:
– Drug dose range checking
– Concentration checking
– Infusion time checking
• Data collection and analysis with this project identified that preproject utilization was much lower than we knew…..
• Collecting the data
– Combining Cerner patient location data with CareFusion
infusion data to produce usage by unit
Guardrails Utilization:
1 month prior vs. 1 month post imp.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
PrePost
PrePost
PrePost
PrePost
PICU-M 6th Floor 7th Floor CVCC-M
PrePost
ICC
PrePost
NICU-M
PrePost
PICU-S
PrePost
PrePost
3200
SCN
PrePost
7940-S
PrePost
PrePost
4100
4200
PrePost
NICU-S
• Safety Gains:
• Each unit has shown an improvement in the percentage of infusions
protected by Guardrails. Range = 4% - 312%. Average increase = 57%.
Inpatient Guardrails Utilization
Sustainability
100%
90%
6th-M
7th-M
80%
CVCC
70%
ICC
NICU-M
60%
PICU-M
50%
SCN
5th-S
40%
6th-S
30%
4100
Epilepsy
20%
NICU-S
10%
PICU-S
0%
Pre-golive %
1 month Post-golive
13-Dec
14-Jul
• Safety Gains:
• All units continue to use Guardrails at a higher rate than
pre-technology rate
• July 2014: 67% of units have maintained or increased
Guardrails utilization since go-live
Programming Method of Guardrails
Protected Infusions
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
PrePost
PrePost
PrePost
PICU-M
6th
Floor
7th CVCC-M
Floor
• Safety Gains:
PrePost
PrePost
ICC
PrePost
PrePost
NICU-M PICU-S
Manual Programming
Auto-ID
PrePost
PrePost
PrePost
PrePost
PrePost
PrePost
3200
SCN
7940
4100
4200
NICU-S
Auto Pump Programming
• Manual programming significantly reduced across all units
• Smart pump programming adopted at high rate across all
units
Alert Reduction with SPP
Alerts per 1000 DERS Infusion Starts
120.0
110.2
100.0
94.8
80.0
74.1
60.0
40.0
20.0
0.0
Jan-12
Jan-13
Jan-14
All Rolled Out – Now What?
• Support is over, right?
• Sustaining standard work
• Appreciate the need for ongoing support/maintenance
–
–
–
–
Nursing Informatics
Pharmacy
Information Technology
BioMed
Sustaining Standard Work
• Informatics nurse rounding process
– Identify issues on the units,
collect issue logs
– Based on compliance data,
meet with individual nurses to
talk about workflow
• Be transparent
– Share data on “good catches”
– Share medication errors where
BCMA was bypassed
Sustaining Standard Work
• Sharing compliance data
– Used to reinforce scanning expectations
– Identify medications that are not scanning or programming
consistently
User Name
CE#####
CE#####
CE#####
CE#####
CE#####
CE#####
CE#####
BCMA
Usage %
97.7%
99.0%
91.9%
87.9%
98.8%
99.2%
100.0%
Patient
Armband
Scan %
95.3%
99.0%
91.9%
84.8%
98.8%
96.0%
100.0%
Medication
Scan %
88.4%
96.9%
91.9%
87.9%
97.6%
91.9%
100.0%
Total
SPP
Events Applied %
43
100%
96
78%
37
71%
33
63%
85
86%
124
87%
32
100%
SPP
Applied
Events
6
14
10
5
18
34
1
SPP
Expected
Events
6
18
14
8
21
39
1
Ongoing Required Support
• Increased urgency for support
– Technology has now become part of patient care vs. just
documentation
– More on-site presence by our Nursing Informaticists
• Additional ongoing testing required
– Upgrades and new code packages
– Network/infrastructure changes
– Updates to Smart Pumps now require integrated testing
• Report generation
– Time consuming
– Complex, merging different data sources
– Time to actually analyze the data and validate once collected is
challenging
Questions?