BC Cancer Agency Dose Error Reduction Software: Choosing the Least Risky IV Pump Sue Fuller Blamey & Karen Janes
Jul 14, 2015
BC Cancer Agency
Dose Error Reduction Software: Choosing the Least Risky IV PumpSue Fuller Blamey & Karen Janes
Objectives
To review two dose error reduction software (DERS) IV pump to identify failure
modes and mitigation strategies
To choose the least risky intravenous pump that includes the most effective mitigation
strategies to prevent IV errors
IV Pump Implementation Team
Team –
Nurses, senior leaders, Quality Director, pharmacists, physicians
Human factors analysis
Conducted Failure Modes Effects Analysis to identify failures, mitigation strategies and
educational plans
Staff IV Pump testing
Root Causes of Failures
DERS Opt in software – staff have to go through multiple steps to opt in
Enter wrong BSA calculation
Culture of staff overriding safety steps
Lack of education
More than one type of pump in use
Forgot to unclamp IV set
FMEA Worksheet Analysis
Seve
rity
Prob
abili
ty
Haz
Sco
re
Sing
le P
oint
W
eakn
ess?
Exis
ting
Con
trol
M
easu
re ?
Det
ecta
bilit
y
Proc
eed?
1 User does not know correct method
Mod
erat
e
unco
mm
on
4 Y Y N Y C
More formal IV pump education
List of stattendingeducatio
HFMEA Subprocess Step Title and Number
Scoring Decision Tree AnalysisHFMEA Step 5 - Identify Actions HFMEA Step 4 - Hazard Analysis
Failure Mode: First Evaluate failure
mode before determining
potential causes
Potential CausesAction Type
(Control, Accept,
Eliminate)
1.1 Incorrect techniques
Actions or Rationale for Stopping
OutcoMeas
Comparing Risk
Risk Alaris Hospira
1. DERS Software Entry/Exit
Higher risk of non- compliance
Opt-out can occur but is not the path of least resistance
2. New Patient Selection
Risk of BSA user- based errors
Low risk with tight DERS limits
3. Loading of IV tubing
Potential for slowed incorrect rate
No risk
Comparing Risk
Risk Alaris Hospira
4. BSA Calculator
No risk – no BSA calculator
Potential for risk of user-based BSA errors
5. Syringe Pump Accuracy
+/- 2% +/- 5% (no paediatrics for BCCA)
6. Server 1 connectivity licence per pump is required to connect to external server
Server sits within PHSA domain
Comparing Risk
Risk Alaris Hospira
7. Wireless Issues with PHSA security network
Server sits within the PHSA network domain
8. Clinical simulation with nurses
More difficult to operate
Easier to prime tubing, more user friendly and intuitive
9. Ergonomic Difficult to open and closeManual loading
Push button/touch screen operatedAutomatic loading
Comparing Risk
Risk Alaris Hospira
10. Risk of repetitive strain injury (RSI)
Standard release system – at risk for RSI
Release system potentially reduces RSI
Overall risk Higher risk Lower risk
Hierarchy of Effectiveness of Interventions
1. Forced functions and constraints2. Automation/computerization3. Simplification/standardization4. Reminders, checklist, double-checks5. Rules and policies6. Education and information
Decision‐making Criteria
Forced functions of DERS Opt out technology forces staff to use DERS unless they go through multiple steps
Implemented a function where nurses have to formally request the Opt out in order to not use DERS