Fentanyl infusions and addressing human error in using smart pump technology.
Chip Royer, RPh, Pharmacy Implementation Specialist, Ivenix
Ivenix wants to thank The Institute for Safe Medication Practice for highlighting an important topic after a recent publication in the South Bend Tribune, “Leaving a discontinued fentanyl infusion attached to the patient leads to a tragic error.” It truly is tragic to think that such an event could still occur after years of using smart pump technology. When “To Err is Human” was first published 21 years ago, we learned not to point fingers. Instead of assigning blame, the industry focused on building technology to help prevent such mistakes. We believe the next big leap in infusion safety has been long overdue.
The Ivenix smart pump technology was designed to promote patient and clinician safety to assist in reducing errors like this patient incident with fentanyl. To this end, the Ivenix system has the following safety features in place to help mitigate these types of errors:
- Largest drug name identified on the pump screen in the industry. We designed the Ivenix pump to clearly display the drug name allowing for Tallman lettering following ISMP recommendations. A secondary label is also available, allowing further clarity for the clinician.
- Single-channel pump helps to simplify programming at the bedside. When programming the Ivenix pump, the clinician addresses one infusion at a time, not multiple.
- Interoperability between the EMR and the pump is essential. At Ivenix, our infusion system was built from the ground up, and we partnered with the leading EMR vendors to incorporate interoperability into our workflows. Scanning the patient, scanning the medication, and then scanning the pump places the CPOE, pharmacist verified, order on the pump for the clinician to review and start. This workflow greatly reduces the chance of programming the wrong drug on the wrong pump.
- Ivenix puts infusion monitoring in the clinician’s hand. Nurses and clinical pharmacists can see infusions programmed outside of normal dosing and take proactive steps to address these. Visibility to infusion status throughout a shift is critical in helping clinicians maintain awareness of what is running and what infusion tasks need to be planned. By providing a remote view to running infusions, the Ivenix Infusion System helps nurses with this burden. Also, integration to third-party alert notification software marries infusion information with patient status events to give added awareness to the status of critical drips. Increasing confidence in care is essential to addressing alert fatigue. Data must be accurate to be trusted and not dismissed by the nurse.
- User-friendly bag and line tracing with bag hooks on the sides allow clear visibility of what is or was infusing.
- The Ivenix Infusion System addresses the end of infusion bag by requiring the nurse to re-enter the VTBI versus a short-cut key which can lead to errors if the person using it is in a hurry or distracted.
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ISMP featured article: https://www.ismp.org/resources/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error
South Bend Tribune article: https://www.southbendtribune.com/story/news/2020/10/31/cancer-researcher-dead-after-indianapolis-hospital-gave-him-fentanyl-rather-than-fluids/116056992/