Medication Error Reduction(MER)with

Graseby Pumps

Raph Samuel13 November, 2003

Medication Error Statistics

• Represent the largest single cause of errors in hospitals

• Eighth leading cause of death

• Accounts for more than 7000 deaths annually in USA alone

• Estimated cost per incident £1600 + 5 day in hospital

Figures from Institute of medicine (IOM)

Common Types of Medication Errors

Common Types of Errors

Distribution of Errors

Percentage

intercepted

PrescribingWrong Dose, Wrong Drug or Allergy

39% 48% CPOE Solutions

TranscribingWrong Dose, Wrong Frequency or Missed Dose

12% 33% CPOE Solutions

DispensingWrong Dose, Wrong Drug, Wrong Time

11% 34% Dispensing Software

AdministeringWrong Dose, Wrong Drug

38% 2% Graseby MER

Solutions

Smiths Business Statement

• Smiths Medical is committed and actively promoting a program to reduce the number and severity of medication errors through the use of Graseby infusion devices. We have added new software features to our existing product line that will help reduce the possibility of incorrectly programming an infusion device at the bedside.

Some areas to address

• Excess manual operations on complex equipment– Drug Protocols, Good pump interface etc.

• Staff competence assessment and training– Programming error log for analysis

• Availability of information– Medical devices connectivity, Patient allergies

etc.• Labelling of medication

– Drugs look and sound similar• Patient identification

– Right patient right medication

Graseby MER SolutionsExcess manual operation

• Graseby Pump Drug Protocols:– Define the pump infusion program and Define the pump infusion program and

Parameters: Infusion mode, Rate, KVO Parameters: Infusion mode, Rate, KVO etc.etc.

– Prepared by ‘clinical experts’Prepared by ‘clinical experts’– Used by ‘non experts’Used by ‘non experts’– Reduces or even eliminates manual Reduces or even eliminates manual

keystrokes to correctly start an infusion keystrokes to correctly start an infusion at POCat POC

– Hard and Soft Parameter LimitsHard and Soft Parameter Limits

Graseby MER SolutionsStaff Assessment and Training

• Develop better system for monitoring and reporting adverse events (Reactive measures):

– Programming error log with nurse and patient identity

– Remote monitoring of multiple pumps– Remote alarms and events alerts– Event history log on pump– Real time remote history download

Graseby MER SolutionsAvailability of Information

• Increase use of Information Technology :– High speed pump networking - TCP/IP– Wireless – 802.11 option– XML/HL7 communication protocol– Encryption– Use conventional computer & PDA– Interface to industry standard PDMS– Use Graseby proprietary PC Software for best

data and protocol remote management

Graseby MER SolutionsLabelling of Medication

• Use of machine-readable coding:– Use barcode on

• Drug– Identifies and displays drug– Could be used to set up infusion

parameters• Patient• Infusion Device• Clinician

Graseby MER Solutions

• Proactive measures to cross-check that easily fits with existing systems:– Right Drug– Right Patient– Right Pump Settings– Right time of medication delivery

Graseby MER SolutionsModular approach

• Stand alone System:

Graseby Pump

Protocol Protocol SoftwareSoftware

Network Comms.

TCP/IPTCP/IP

XML/HL7XML/HL7

EncryptionEncryption

Barcode Reader

Graseby MER SolutionsModular Approach Cont.

• Locally Connected System:

Graseby Pump Monitoring

and Management

Software

MEDSHIELDMEDSHIELD

Input Device

Display

Graseby Pump

Protocol Protocol SoftwareSoftware

Network Comms.

TCP/IPTCP/IP

XML/HL7XML/HL7

EncryptionEncryption

Barcode Reader

Graseby MER SolutionsModular Approach Cont.

• Hospital Networked System:

Patient Data Management

Software

e.g. Siemense.g. Siemens

Graseby Pump

Protocol Protocol SoftwareSoftware

Network Comms.

TCP/IPTCP/IP

XML/HL7XML/HL7

EncryptionEncryption

Barcode Reader

Graseby MER Future Progress

What do we need to do now:– Establish close co-operation with societies

suchas SCATA

– Define a Master Drug Library (MDL)– Establish a working arrangements with

hospitals to try out different ideas in • Initially, non clinical environment• Eventually in clinical application