Revised guidelines for smart infusion pump safety released

Feb. 18, 2020

The Institute for Safe Medication Practices (ISMP) has published updated guidelines to help healthcare organizations maximize the safety benefits of smart infusion pumps, and better position their organizations for bi-directional interoperability with an electronic health record. ISMP, an independent watchdog organization, published its original smart infusion pump guidelines in 2009.

“Infusion pump-related errors have frequently occurred due to a failure to engage the dose error-reduction system and the ease with which providers may select the wrong drug library entry or override serious alerts,” says ISMP Director of Consulting Services Michelle Mandrack. “ISMP has sought input from end users and key stakeholders to identify safety gaps and expand the compendium of expert-and evidence-based best practices available in this area to better protect patients.”

To gather information for the updated guidelines, ISMP held a smart infusion pump summit in 2018 to discuss issues raised by errors reported to the ISMP National Medication Errors Reporting Program (ISMP MERP) and published in the literature since the original guidelines were issued. The second summit was funded by an educational grant from Baxter, B. Braun, BD, ICU Medical and Ivenix. Participants included organizational end users, smart infusion pump vendors, and representatives of professional and regulatory organizations, who focused on gaining consensus on safe practices that were incorporated into the updated guidelines.

Even when organizations optimize the use of smart infusion pump technology, problems can still exist, often stemming from pumps operating in isolation of other electronic systems, such as electronic health records, and requiring manual programming and documentation by the end user.

ISMP also conducted three practitioner surveys to better assess successes, safety concerns and barriers to the optimal operation of smart infusion pumps. The barriers identified included significant limitations of pump capabilities, alarm fatigue, persistent deficiencies related to library use and updates, availability of pumps, programming workflow, associated risks with secondary infusions and pump data analysis.

The updated guidelines outline specific error-reduction strategies to address these barriers. In 2020, ISMP formally affiliated with ECRI.

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