Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

March 2020

ISMP Smart Infusion Pump Guidelines

A year ago (see our March 5, 2019 Patient Safety Tip of the Week “Infusion Pump Problems”) we did an extensive column on safety issues related to infusion pumps. We hope you’ll go back to that column to review our many recommendations.

But ISMP (Institute for Safe Medication Practices) has now published its long awaited “Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps” (ISMP 2020). We have no intention of replicating here the details of that thorough, practical, up-to-date guideline. You’ll have to read it yourselves.

It describes the various types of errors associated with infusion pumps, including dose-rate and infusion-rate mix up errors, concentration errors, multiple line errors, and others. It summarizes results of several surveys that ISMP undertook in recent years on infusion pump issues and then discusses infrastructure issues, drug library issues, clinical workflow issues, continuous quality improvement (CQI) data, and interoperability with the electronic health record. There is also a section on clinical alerts, soft limits, hard limits, and alarm management.

The guideline also discusses dose error-reduction systems (DERS), a feature of some smart pumps. Facility-customized DERS warn healthcare providers about potential prescribing, calculation, and programming errors by generating alerts intended to prevent infusions from being programmed outside facility-established limits.

The section on building a drug library is especially important. ISMP stresses independent double checking for the entry or modification of each drug-specific element such as the

standardized drug name, applicable tall man lettering, dosing units, concentration, dose limits, and associated clinical alerts.

ISMP recommends you establish care areas/profiles that are tailored to specific patient populations, acuity, and/or patient weight. But you must remember when transferring patients to a different clinical unit to ensure the drug library care area/profile is appropriate for the receiving unit.

Standardization is critical. That includes standardizing the nomenclature of the drug name (including any TALL MAN LETTERING), dose/dosing units (e.g., weight-based versus non-weight-based dosing; mcg/kg versus mg/kg), and dose-rate (e.g., mg/kg/min versus mg/kg/hr) in the drug library. It is also important to make sure this nomenclature is consistent with the EHR, pharmacy infusion labels, and pharmacy IV workflow systems. Standardizing and limiting the number of drug concentrations for continuous and intermittent infusions in the drug library is also important.

Performance of double checks at certain points in the clinical workflow is emphasized. When starting selected facility-defined high-alert medication infusions and at additional facility-defined steps (e.g., change of shift/handoffs, change in the rate/dose of infusion, change in bag/bottle/syringe) require that a double check be performed and documented to verify the following before starting the infusion:

Patient
Patient weight used for weight-based medications
Drug/solution
Drug concentration
dose-rate of continuous infusions, dose and rate of intermittent infusions
Channel selection
Line attachment

ISMP notes that technology (eg. barcoding) is the preferred method for double checking most of these items but use of a second practitioner is necessary to perform and document an independent double check for line attachment.

It outlines considerations for differentiating infusion pumps used to administer medications and fluids via different routes of administration (e.g., IV, enteral, epidural).

One often overlooked point: “Immediately discard all continuous IV medications and epidural infusions (e.g., continuous infusions of magnesium, neuromuscular blocking agents, and opioids) after discontinuation (i.e., do not leave hanging on an IV pole or at the bedside).”

The ISMP guideline is aimed primarily at use of smart infusion pumps in facilities. It does not delve into issues related to use of infusion pumps in the home setting. We covered some of the latter issues in our March 5, 2019 Patient Safety Tip of the Week “Infusion Pump Problems”. Especially important in the home setting is one of our own critical warnings that applies to any sort of infusion pump, smart or otherwise: never put a potentially lethal amount of a medication in a bag/bottle/syringe, lest some sort of error leads to infusion of the entire amount over too short a period. We have done several columns in which fatal or near-fatal overdoses of chemotherapy agents have been infused inadvertently over several hours when they had been intended to infuse over several days (see our Patient Safety Tips of the Week for September 11, 2007 “Root Cause Analysis of Chemotherapy Overdose” and April 6, 2010 “Cancer Chemotherapy Accidents” and September 15, 2015 “Another Possible Good Use of a Checklist”).

The ISMP guideline also includes multiple metrics that should be monitored as part of your quality improvement program.

This ISMP guideline is a must-read for anyone who encounters infusion pumps in their practice. It has a strong evidence base, is well-referenced, and has many practical recommendations.

As above, we hope you’ll also go back to our March 5, 2019 Patient Safety Tip of the Week “Infusion Pump Problems” for our extensive review of safety issues related to infusion pumps. The current ISMP guidelines also don’t go into detail about some of the special issues involved with PCA (patient-controlled analgesia) pumps. We’ve also included below a list of our prior columns dealing with PCA issues.

Our prior columns related to infusion pump issues:

May 2010 “FDA's Infusion Pump Safety Initiative”
April 27, 2010 “Infusion Pump Safety”
August 2016 “Home Infusion Therapy Pitfalls”
March 5, 2019 “Infusion Pump Problems”

Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:

January 4, 2011 “Safer Use of PCA”
July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression”
May 12, 2009 “Errors With PCA Pumps”
September 21, 2010 “Dilaudid Dangers”
November 2010 “More on Preoperative Screening for Obstructive Sleep Apnea”
February 22, 2011 “Rethinking Alarms”
May 17, 2011 “Opioid-Induced Respiratory Depression – Again!”
September 6, 2011 “More Tips on PCA Safety”
December 6, 2011 “Why You Need to Beware of Oxygen Therapy”

February 21, 2012 “Improving PCA Safety with Capnography”

September 2012 “Joint Commission Sentinel Event Alert on Opioids”
September 2012 “FDA Warning on Codeine Use in Children Following Tonsillectomy”
July 3, 2012 “Recycling an Old Column: Dilaudid Dangers”
February 12, 2013 “CDPH: Lessons Learned from PCA Incident”
February 19, 2013 “Practical Postoperative Pain Management”
May 6, 2014 “Monitoring for Opioid-induced Sedation and Respiratory Depression”
March 3, 2015 “Factors Related to Postoperative Respiratory Depression”
June 2, 2015 “Reminders of Dilaudid Dangers”
August 11, 2015 “New Oxygen Guidelines: Thoracic Society of Australia and NZ”
August 18, 2015 “Missing Obstructive Sleep Apnea”
December 2015 “Opioid Alert Fatigue”
March 2016 “Guideline for Management of Postoperative Pain”
June 14, 2016 “Nursing Monitoring of Patients on Opioids”
October 11, 2016 “New Guideline on Preop Screening and Assessment for OSA”
December 6, 2016 “Postoperative Pulmonary Complications”
May 2017 “Another Twist in Opioid-Induced Respiratory Depression”
June 2017 “Masterpiece: Monitoring for Opioid-Induced Respiratory Depression”
June 20, 2017 “Dilaudid Dangers #4”
October 3, 2017 “Respiratory Compromise: One Size Does Not Fit All”
November 2017 “Bad Combination: Gabapentin and Opioids”
November 21, 2017 “OSA, Oxygen, and Alarm Fatigue”
July 31, 2018 “Surgery and the Opioid-Tolerant Patient”
February 12, 2019 “2 ER Drug Studies: Reassurances and Reservations”
March 2019 “Gabapentin and Pregabalin on the Radar Screen”
June 18, 2019 “Found Dead in a Bed”
January 2020 “FDA Warning on Gabapentinoids”
January 2020 “Opioids and Apnea: Not Just Surgical Patients”

Tools: PCA Pump Audit Tool and the PCA Pump Criteria

References:

ISMP (Institute for Safe Medication Practices). Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. ISMP 2020; February 10, 2020

https://www.ismp.org/guidelines/safe-implementation-and-use-smart-pumps

(ISMP 2020)

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