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Human-Based Errors Involving Smart Infusion Pumps: A Catalog of Error Types and Prevention Strategies.

ABSTRACT: Over 4000 preventable injuries due to medication errors occur each year in any given hospital. Smart pumps have been widely introduced as one means to prevent these errors. Although smart pumps have been implemented to prevent errors, they fail to prevent specific types of errors in the medication administration process and may introduce new errors themselves. As a result, unique prevention strategies have been implemented by providers. No catalog of smart pump error types and prevention strategies currently exists. The aim of this study is to review and catalog the types of human-based errors related to smart pump use identified in the literature and to summarize the associated error-prevention strategies. We searched MEDLINE, PubMed, PubMed Central, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for literature pertaining to human-based errors associated with smart pumps. Studies related to smart pump implementation, other types of pumps, and mechanical failures were excluded. Final selections were mapped for error types and associated prevention strategies. A total of 1177 articles were initially identified, and 105 articles were included in the final review. Extraction of error types and prevention strategies resulted in the identification of 18 error types and ten prevention strategies. Through a comprehensive literature review, we compiled a catalog of smart pump-related errors and associated prevention strategies. Strategies were mapped to error types to provide an initial framework for others to use as a resource in their error reviews and improvement work. Future research should assess the application of the resources provided by this review.

SUBMITTER: Kirkendall ES

PROVIDER: S-EPMC7750013 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND:The adverse event report of medical devices is one of the postmarket surveillance tools used by regulators to monitor device performance, detect potential device-related safety issues, and contribute to benefit-risk assessments of these products. However, with the development of the related technologies and market, the number of adverse events has also been on the rise, which in turn results in the need to develop efficient tools that help to analyze adverse events monitoring data and to identify risk signals. OBJECTIVE:This study aimed to establish a hazard classification framework of medical devices and to apply it over practical adverse event data on infusion pumps. Subsequently, it aimed to analyze the risks of infusion pumps and to provide a reference for the risk management of this type of device. METHODS:The authors define a general hierarchical classification of medical device hazards. This classification is combined with the Trace Intersecting Theory to form a human-machine-environment interaction model. Such a model was applied to the dataset of 2001 to 2017 class I infusion pump recalls extracted from the Food and Drug Administration (FDA) website. This dataset does not include cases involving illegal factors. RESULTS:The proposed model was used for conducting hazard analysis on 70 cases of class I infusion pump recalls by the FDA. According to the analytical results, an important source of product technical risk was that the infusion pumps did not infuse accurate dosage (ie, over- or underdelivery of fluid). In addition, energy hazard and product component failure were identified as the major hazard form associated with infusion pump use and as the main direct cause for adverse events in the studied cases, respectively. CONCLUSIONS:The proposed human-machine-environment interaction model, when applied to adverse event data, can help to identify the hazard forms and direct causes of adverse events associated with medical device use.

Project description:BackgroundInfusion Pumps (IP) are medical devices that were developed in the 1960s and generate fluid flow at pressures higher than that of normal blood pressure. Various hospital sectors make use of them, and they have become indispensable in therapies requiring continuity and precision in the administration of medication and/or food. As they are classified Class III (high risk) equipment, their maintenance is crucial for proper performance of the device, as well as patient and operator safety. The principal consideration of the pump is the volume infused, and the device demands great attention to detail when being calibrated. A lack of necessary care with this equipment can lead to uncertainty in volume and precision during the administration of substances. Because of this, it is essential to evaluate its reliability, to prevent possible failures at time of execution. This control aims at the quality of the intended infusion result, becoming an indication of quality.MethodsThis systematic review summarizes studies done over the last 10 years (2011 to December 2021) that address the reliability and accuracy of hospital infusion pumps, in order to identify planning of maintenance and/or other techniques used in management of the equipment. The Prisma method was applied and the databases utilized were Embase, MEDLINE/Pubmed, Web of Science, Scopus, IEEE Xplore, and Science Direct. In addition, similar reviews were studied in Prospero and the Cochrane Library. For data analysis, softwares such as Mendeley, Excel, RStudio, and VOSviewer were used, and Robvis helped in plotting risk of bias results for studies performed with Cochrane tools.ResultsThe six databases selected produced 824 studies. After applying eligibility criteria (inclusion and exclusion), removing duplicates, and applying filters 1 and 2, 15 studies were included in the present review. It was found that the most relevant sources came from the Institute of Electrical and Electronics Engineers (IEEE) and that the most relevant keywords revolved around the terms ("device failure", "infusion pumps", "adverse effects", "complications", etc.). These results made clear that there remains substantial room for improvement as it relates to the study of accuracy and reliability of infusion.ConclusionsWe verified that the reliability and precision analysis of hospital infusion pumps need to be performed in a more detailed and consistent way. New developments, considering the model and IP specification, are intended, clearly explaining the adopted methodology.

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Human-Based Errors Involving Smart Infusion Pumps: A Catalog of Error Types and Prevention Strategies.

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