Back in April, The Joint Commission (TJC) issued Sentinel Event Alert #63. Did you get a chance to read it? If not, you should because It contains valuable information from the Institute for Safe Medication Practices (ISMP) and Emergency Care Research Institute (ECRI) on smart infusion pumps that you will want to become familiar with.
But let’s dive into it a little here…
Smart Infusion Pumps
Infusion pump “guardrails” are put in place to help reduce medication errors. You will want to note that the name they refer to these guardrails – the software inside the infusion pump that contains the library of correct dosages and infusion rates – as “Dose Error Reduction Software,” or DERS for short.
Alert #63 comes with information discussing the safety strategies for the use of smart infusion pumps and the root causes of infusion pump errors—both human and technical.
Although DERS software has been on the market for 15+ years, medication errors can and still happen, as proven in a 2016 study which found that about 10% of all infusion medication errors occurred because someone bypassed the system.
According to this Alert, there are several actions that you can take to reduce the risk of these medication errors in your organization:
- A multidisciplinary team or department is assigned with the responsibility of overseeing the interoperability of smart infusion pumps
- There is a process to create, test, and maintain a drug library
- Staff is trained and competent
- Optimizing the use of DERS
- Monitoring any and all alerts, overrides, recalls, and adverse events or close-calls
- Connecting smart pump to your EHR/EMR system (if capable)
- Identifying and addressing human and environmental factors that contribute to errors
- Protect smart pumps from cybersecurity threats.
As with any Sentinel Event Alert, there is currently NO mandate from TJC to implement all of the recommendations contained in the alert.
Do not let that distract you from the significance of this Alert. This topic seems like a good surveyor conversation topic at a medication management system tracer.
You certainly would not want to be in a position of stating you have not seen the alert or have not considered the recommendations so we encourage you to evaluate and determine which are appropriate for your organization.
Patton Healthcare Consulting
We can help you plan and implement strategies that avoid smart infusion pump errors, so contact us today!