Unsafe medication doses caught just in time

August 24, 2016

Highly-skilled and busy healthcare professionals are always acting in the best interests of patients. Even so, an honest mistake at the bedside can result in harm no one intended.

Patients have a lot of needs; one of them is to get the right medication, at the right dose, in the right concentration and at the right rate to help ensure a positive outcome. And that’s just what smart IV pumps, like the ones currently being rolled out throughout the provincial healthcare system, are designed to do. In fact, if a dose is either too high or too low, the pump alerts the healthcare provider and stops the medication from flowing until a correction or manual override has been made.

To date, thousands of safety alerts have been issued by the pumps at the patient bedside, allowing the medication doses to be reviewed and corrected by healthcare providers before a potential medication error reaches the patient.

Data collected between April 4 and June 3 from the first three health organizations to implement the new pumps show that from over 200,000 infusion programs, the pumps’ error reduction software stopped more than 4,400 infusions initially programmed outside of safe dosing limits, preventing potential medication errors that in some cases could have resulted in serious patient outcomes.

“These early statistics are so encouraging,” says Susie Hilton, Clinical Director for 3sHealth and the project’s provincial lead. “We, meaning the health system partners who collaborated to make this decision, were confident that this new technology would improve patient safety and potentially save lives and the data is showing that it is.”

The biggest reason why the pumps are so effective is that they are programmed to work in conjunction with a single provincial drug library, which was created by a provincial committee of pharmacists, nurses and physicians. The provincial drug library is the first of its kind in Canada and it’s based on leading practices and guidelines from the Institute of Safe Medication Practices Canada. The drug library is updated periodically in response to submissions from clinicians who use the pumps and by review of utilization trends identified in the quality improvement reports generated through the pumps’ software.

“Most of the credit for making this initiative such a success goes to clinicians,” said Hilton. “They are consistently using the new error reduction software more than 98 per cent of the time. If it wasn’t for this tremendous uptake, we wouldn’t be seeing the kinds of results we are.”

“The compliance statistics are really impressive,” says Hicham El Hajj, who works with Hospira, the smart pumps vendor. “I can honestly say that we have never seen compliance numbers this high in a project.”

To date, seven health regions (Regina Qu’Appelle, Heartland, Mamawetan Churchill River, Prairie North, Sun Country, Sunrise and Keewatin Yatthe) and the Saskatchewan Cancer Agency’s Allan Blair Clinic have implemented the new Hospira smart pumps. A total of 1,600 pumps have been deployed to these health region partners, with an additional 93 pumps going to Saskatchewan Polytechnic, 10 to the University of Saskatchewan and four to Peter Ballantyne Cree Nation Health Services. The remaining regions are preparing for implementation in the fall, with all regions and the Saskatchewan Cancer Agency in Saskatoon targeted for completion by mid-December.


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