From the Regenstrief Center for Healthcare Engineering, and.
Department of Industrial Engineering and Management, Ben Gurion University of the Negev, Beersheba, Israel.
J Patient Saf. 2019 Mar;15(1):e8-e14. doi: 10.1097/PTS.0000000000000562.
Our previous study showed that the issue of drug library update delays on wireless intravenous (IV) infusion pumps of one major vendor was widespread and significant. However, the impact of such a delay was unclear. The objective of this study was to quantify the impact of pump library update delays on patient safety in terms of missed and false infusion programming alerts.
The study data sets included infusion logs and drug libraries from three hospitals of one health system from January 2015 to December 2016. We identified limit setting changes of any two consecutive drug library versions. We quantified the impact of using outdated drug limit settings by missed and false infusion programming alerts.
Twenty-five updates of the drug library were released within the health system during the 2-year period with an average interval of 28.8 days. After a new library version was issued, it took at least 6 days for 50% of all pumps to become up-to-date and 15 days or more to reach 80%. All three hospitals had at least 16% of all IV infusions programmed with outdated libraries. This resulted in 18%, 24.4%, and 27% of false alerts in the three hospitals, respectively. We identified two cases of missed alert infusions of high-risk medications, propofol, and potassium chloride, which could have negatively impacted patient safety.
These findings support our assumption that potential serious harm can happen when IV infusions are administered with outdated drug limit settings due to delays in drug library updates on the pump.
我们之前的研究表明，一家主要供应商的无线静脉（IV）输注泵的药物库更新延迟问题广泛且严重。然而，这种延迟的影响尚不清楚。本研究的目的是从错过和错误的输液编程警报的角度，量化泵库更新延迟对患者安全的影响。
该研究的数据包括来自一个医疗系统的三家医院的输液记录和药物库，时间为 2015 年 1 月至 2016 年 12 月。我们确定了任何两个连续药物库版本的限制定值更改。我们通过错过和错误的输液编程警报来量化使用过时药物限制定值的影响。
在 2 年期间，该医疗系统共发布了 25 次药物库更新，平均间隔为 28.8 天。在发布新的库版本后，至少需要 6 天才能使所有泵中的 50%保持最新状态，而达到 80%则需要 15 天或更长时间。所有三家医院都有至少 16%的所有 IV 输液使用过时的库进行编程。这导致三家医院的错误警报率分别为 18%、24.4%和 27%。我们发现了两例高风险药物（异丙酚和氯化钾）漏报输注的情况，这可能会对患者安全产生负面影响。
这些发现支持我们的假设，即在由于泵上的药物库更新延迟而导致使用过时的药物限制定值进行 IV 输液时，可能会发生潜在的严重伤害。
