Pharmacy Practice Newsrecently published a list of leading medication errors compiled by ISMP and FDA/ISMP Safe Medication Management Fellows. The list and strategies to combat these errors represent the period of January through December 2020. The article contains the problematic medication or device, followed by a description, a section detailing the ISMP recommendations and strategies, and a section that lists technology that could help prevent or detect such errors. The list is an excellent resource for pharmacists to review, especially regarding the technology used to prevent medication errors.
Problem: Bypassing soft low dose limits for high alert medications such as Heparin
Establishing soft/hard limits with visual DERS for bolus and continuous infusions allows maximum protection by displaying settings graphically for additional verification. By presenting these infusion administration safety limits in picture form, drug librarians have a second view of the work at hand. Recently, while converting a legacy pump drug library to the Ivenix drug library, a colleague realized they had no hard limits associated with several medications. The pharmacist caught this error because of the visual DERS available during the review phase of the project. This secondary check gave the pharmacist the additional peace of mind that the library is configured as intended.
Figure 1: Visual DERS displayed by Ivenix large volume pump
Adding dosing modifiers to account for different clinical indications helps narrow the dosing for specific clinical situations. And auto-programming of infusions takes the provider’s order, verified by pharmacy, and auto-populates the pump with the intended patient, drug, dose, and rate.
Problem: Keeping pumps outside of COVID-19 patients’ rooms
Boasting the largest, most colorful touchscreen in the smart pump space, Ivenix sets the standard for allowing clear visibility to infusions from a distance. When an Ivenix infusion pump is placed inside a patient’s room, the large and bright display enables healthcare workers to safely see the programmed infusion from meters away. A remote view allows healthcare providers an unparalleled look into their patient’s medication delivery via an infusion dashboard. Nurses administering treatment, as well as pharmacists, can “follow” a patient’s infusion status from a mobile device and virtually review infusion status, see when bags are empty, and observe alarm conditions from anywhere in the hospital.
Figure 2: Ivenix Infusions Dashboard provides visibility to infusion status
Problem: Incomplete administration of intermittent medications
Legacy infusion pumps struggle with solving the problem of infusing an intermittent medication via a secondary line while still administering the entire prescribed dose. Ivenix’s unique administration set and patented workflow allows for complete administration of the intermittent – including overfill – and then allowing the carrier fluid on the primary line to flush the line completely, thus administering the entire dose of medication.
Figure 3: Legacy infusion pump example
Figure 4: Ivenix LVP infuses until empty
Problem: Using smart pump technology in the OR setting by anesthesia providers
Smart pump technology is utilized in most hospitals in the United States today within all areas and departments. The OR department should be no exception for their use as the specific needs of the OR team can be supported without sacrificing flexibility.
Ivenix believes all dosing limits should involve the collaboration of anesthesia providers, just like bedside clinicians. To err is human, why would a hospital be comfortable with allowing an anesthesia provider to override a hard limit while programming an infusion? While operating in “anesthesia mode,” some legacy smart pumps permit this hard limit override. Ivenix thinks the best practice is to consult with the anesthesia professionals to establish safe infusion parameters and add the configurations into the drug library. If all agree that hard limits for certain medications bring essential safety to the hospital, establish those limits, and restrict overriding and exceeding those limits. Ivenix supports this practice of applying hard limits to anesthesia care profiles and recommends anesthesia providers be stopped from overriding reasonable hard limits.
At Ivenix, we think differently! The Ivenix Large Volume Pump is built from the ground up to meet the newest and most stringent U.S. FDA infusion pump guidelines aimed at addressing the recurring safety issues and concerns of legacy smart pumps.