Pursuing Excellence in Medication Safety: Standardizing Infusion Pump Drug Libraries Across a Health System

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In this issue of Pharmacy Practice in Focus: Health Systems, Shanna Schneider, PharmD, BCPS, and Brandon McLain, PharmD, MBA, BCPS, provide a summary of the work they have done within their health system to meet an Institute for Safe Medication Practices (ISMP) guideline for standardizing their infusion pump drug libraries to a single library.¹ On the surface, this would seem to be a relatively simple and logical expectation for a health system, but as Schneider and McLain explain, it is a complex project requiring the engagement of multiple stakeholders.

Smart infusion pumps and their integrated dose error reduction systems, the settings of which are often referred to as guardrails, are driven by a drug library that is developed and maintained at a local level. That is, every institution builds its own library and establishes its own governance structure for how the database is maintained, and the frequency of updates can vary widely across institutions, from monthly to yearly or longer. There isn’t exactly a “standard” for this, although ISMP and other organizations have provided detailed guidelines for consideration.

As we know, health care has a patient safety problem. The World Health Organization estimates that 1 in every 10 patients is harmed while being cared for in a health care facility. This results in more than 3 million deaths annually worldwide, with more than 50% of that harm being preventable. Estimates also suggest that medication-related harm affects 1 in 30 patients, with more than 25% of events considered serious or life-threatening.²

The administration of intravenous (IV) high-risk medications (eg, insulin, opiates, vasopressors, inotropes) is one of the riskiest things we do for acute care patients with complex issues. Smart pumps were introduced as a sharp-end technology to improve the safety of IV drug and fluid administration; however, it remains unclear whether health care as an industry has embraced this mission of safety as it relates to implementing this technology. My experience is that we will spend millions of dollars on the technology but fall short on investing in the implementation, training, process improvement, and accountability expectations to achieve the safety and quality the technology promises. I do not know of many other industries that would invest in a technology like this but then have what is essentially a laissez-faire approach to its actual implementation and use.

The lack of national standards for drug concentrations and safe infusion limits has been discussed for years, but little has been achieved toward that goal. The ISMP guidelines have set goals of 95% or greater for adherence to the use of smart pumps, guardrails, and electronic medical record (EMR) interoperability functionality. Although laudable in principle, this goal would also mean we are saying it is acceptable to allow 1 in 20 infusions without standard safety measures being in place. At the largest institution in my health system, that would amount to almost 14,000 infusions per quarter not meeting our standards. I am not sure whether 95% adherence provides sufficient confidence in the safety of our systems.

In health care, we like to make comparisons with the airline industry, which, despite some of its recent woes, remains one of the more reliable industries from a safety perspective. The Federal Aviation Administration (FAA) handles approximately 45,000 flights per day across 520 air traffic control towers. It keeps about 5400 aircraft safe in the sky at peak operational times, carrying 2.9 million passengers daily and 44.5 billion pounds of freight per year.³ Every plane undergoes a safety inspection, and its crew must complete a safety checklist before every flight. If the FAA set that safety expectation at 95% of flights, that would translate to 2250 flights taking off daily with no safety inspections. Further, every hospital or health system creating its own safety database for infusions would be the equivalent of each of the 520 air traffic control towers creating its own standards and policies. That would result in havoc and a loss of safety. In health care, we too often make excuses for our unacceptably low standards for quality and safety that are not genuinely defensible. For example, I am frequently told the emergency department is too fast-paced and hectic to consistently use guardrails and interoperability when we review our data, but safety technology would be most helpful in a fast-paced, hectic environment.

Additionally, the level of training on the proper use of smart pump functionality is inconsistent. More importantly, the level of understanding of the purpose and value of sharp-end technologies is often subpar, and it appears to have worsened with the increased use of temporary staff in health systems over the past several years. We argue against using hard stops in our workflows to force the use of technology in the name of safety in emergent situations. However, it is ironic that we sacrifice safety most of the time in the name of safety, rather than creating override processes that can be used in genuinely emergent situations.

As much as we like to believe that each hospital in a health system or each health system in the country has unique needs, the reality is that these drugs do the same thing and carry the same risks everywhere. There is no reason that we cannot establish a national standard for drug concentrations, management of overfill volumes, drug libraries, hard and soft limits on infusion rates, and interoperability with EMRs. Drug library updates could be pushed out on a set schedule, and libraries specific to different patient care environments (eg, pediatrics, neonatal intensive care unit, adult, intensive care unit, etc) could be established.

If we are serious about investing in patient safety as it relates to sharp-end technologies like smart pumps, we must stop making excuses for not using the technology and stop accepting 95% as acceptable utilization. We also need to establish systems that hold health care workers accountable for using the technology their health system has adopted and implemented. Other industries do not make such use optional for their workforce.

REFERENCES

1. Guidelines for optimizing safe implementation and use of smart infusion pumps. Institute for Safe Medication Practices. February 10, 2020. Accessed August 12, 2024. https://www.ismp.org/guidelines/safe-implementation-and-use-smart-pumps

2. Patient safety. World Health Organization. September 11, 2023. Accessed August 12, 2024. https://www.who.int/news-room/fact-sheets/detail/patient-safety

3. Air traffic by the numbers. Federal Aviation Administration. Updated June 20, 2024. Accessed August 12, 2024. https://www.faa.gov/air_traffic/by_the_numbers