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Minimal research has been conducted into the potential patient safety issues related to administering multiple intravenous (IV) infusions to a single patient. Previous research has highlighted that there are a number of related safety risks. In Phase 1a of this study, an analysis of 2 national incident-reporting databases (Institute for Safe Medica...
Citations
... Considering the findings of this study and in vitro studies of infusion startup delay and infusion "no-flow" interruptions [33], as well as the influence of administration line compliance [34], filters [35], the interplay between multiple infusions [36], and resistance from backcheck and antisyphon valves [35], the risks of protracted and clinically important nondelivery and occlusion are likely at low rates, particularly below rates of 0.5 mL/hr [35]. The study's findings suggest a balance between the need to restrict fluid delivery to patients and maintaining the integrity and longevity of infusion might be best achieved with a rate ranging from >2.0 to ≤2.4 mL/hr (ratio 0.985), although the next higher rate of >2.4-≤2.8 ...
Background: Infusion failure may have severe consequences for patients receiving critical, short-half-life infusions. Continued interruptions to infusions can lead to subtherapeutic therapy.
... Considering the findings of this study and in vitro studies of infusion startup delay and infusion "no-flow" interruptions [33], as well as the influence of administration line compliance [34], filters [35], the interplay between multiple infusions [36], and resistance from backcheck and antisyphon valves [35], the risks of protracted and clinically important nondelivery and occlusion are likely at low rates, particularly below rates of 0.5 mL/hr [35]. The study's findings suggest a balance between the need to restrict fluid delivery to patients and maintaining the integrity and longevity of infusion might be best achieved with a rate ranging from >2.0 to ≤2.4 mL/hr (ratio 0.985), although the next higher rate of >2.4-≤2.8 ...
Background
Infusion failure may have severe consequences for patients receiving critical, short–half-life infusions. Continued interruptions to infusions can lead to subtherapeutic therapy.
Objective
This study aims to identify and rank determinants of the longevity of continuous infusions administered through syringe drivers, using nonlinear predictive models. Additionally, this study aims to evaluate key factors influencing infusion longevity and develop and test a model for predicting the likelihood of achieving successful infusion longevity.
Methods
Data were extracted from the event logs of smart pumps containing information on care profiles, medication types and concentrations, occlusion alarm settings, and the final infusion cessation cause. These data were then used to fit 5 nonlinear models and evaluate the best explanatory model.
Results
Random forest was the best-fit predictor, with an F1-score of 80.42, compared to 5 other models (mean F1-score 75.06; range 67.48-79.63). When applied to infusion data in an individual syringe driver data set, the predictor model found that the final medication concentration and medication type were of less significance to infusion longevity compared to the rate and care unit. For low-rate infusions, rates ranging from 2 to 2.8 mL/hr performed best for achieving a balance between infusion longevity and fluid load per infusion, with an occlusion versus no-occlusion ratio of 0.553. Rates between 0.8 and 1.2 mL/hr exhibited the poorest performance with a ratio of 1.604. Higher rates, up to 4 mL/hr, performed better in terms of occlusion versus no-occlusion ratios.
Conclusions
This study provides clinicians with insights into the specific types of infusion that warrant more intense observation or proactive management of intravenous access; additionally, it can offer valuable information regarding the average duration of uninterrupted infusions that can be expected in these care areas. Optimizing rate settings to improve infusion longevity for continuous infusions, achieved through compounding to create customized concentrations for individual patients, may be possible in light of the study’s outcomes. The study also highlights the potential of machine learning nonlinear models in predicting outcomes and life spans of specific therapies delivered via medical devices.
... Several studies have reported equipment issues. 10,28 In addition, participants pointed out the need for advanced monitoring equipment for patients with infectious diseases in isolation rooms. ...
Purpose:
Medication administration is a complex process and constitutes a substantial component of nursing practice that is closely linked to patient safety. Although intravenous fluid administration is one of the most frequently performed nursing tasks, nurses' experiences with intravenous rate control have not been adequately studied. This study aimed to explore nurses' experiences with infusion nursing practice to identify insights that could be used in interventions to promote safe medication administration.
Patients and methods:
This qualitative descriptive study used focus group interviews of 20 registered nurses who frequently administered medications in tertiary hospitals in South Korea. Data were collected through five semi-structured focus group interviews, with four nurses participating in each interview. We conducted inductive and deductive content analysis based on the 11 key topics of patient safety identified by the World Health Organization. Reporting followed the consolidated criteria for reporting qualitative research (COREQ) checklist.
Results:
Participants administered infusions in emergency rooms, general wards, and intensive care units, including patients ranging from children to older adults. Two central themes were revealed: human factors and systems. Human factors consisted of two sub-themes including individuals and team players, while systems encompassed three sub-themes including institutional policy, culture, and equipment.
Conclusion:
This study found that nurses experienced high levels of stress when administering infusions in the correct dose and rate for patient safety. Administering and monitoring infusions were complicated because nursing processes interplay with human and system factors. Future research is needed to develop nursing interventions that include human and system factors to promote patient safety by reducing infusion-related errors.
... When an error occurs involving IV medications, it is often difficult to detect (Cassano-Piché et al., 2012) and poses significant risk to the patient due to the drugs' commonly low therapeutic thresholds and rapid onsets (Ding et al., 2015;Fahimi et al., 2015). The majority of ADEs involving medications delivered via IV infusion are a result of programming errors (NQF, 2012). ...
... The programming of IVSP requires a high level of cognitive demand because IVSP involve many steps and significant human-device interaction (Campoe & Giuliano, 2017;Giuliano, 2018a). Higher cognitive demands are consequential because they compromise a nurse's ability to provide safe patient care (Cassano-Piché et al., 2012;Jennings, 2021). Risk of error is exacerbated in the ICU, where nurses experience high cognitive demands related to the large volume of required patient care tasks, high medical acuity and frequent interruptions from families, other staff and medical alarms (Cassano-Piché et al., 2012). ...
... Higher cognitive demands are consequential because they compromise a nurse's ability to provide safe patient care (Cassano-Piché et al., 2012;Jennings, 2021). Risk of error is exacerbated in the ICU, where nurses experience high cognitive demands related to the large volume of required patient care tasks, high medical acuity and frequent interruptions from families, other staff and medical alarms (Cassano-Piché et al., 2012). In this environment, reliance on IVSP is especially high, with patients receiving an average of seven IV medications per day (Moss et al., 2008). ...
Aim:
To understand the experience of critical care nurses when performing common, yet error-prone, programming tasks on two unfamiliar intravenous smart pumps.
Design:
A qualitative descriptive study using data collected during a previous quantitative pilot study.
Methods:
Following completion of common intravenous programming tasks each participant was interviewed using a semi-structured interview guide. All interview data were coded line-by-line and thematic analysis revealed themes across all participants' interviews.
Results:
The following four themes were identified: appreciation for attractive design features, the need for efficiency, the importance of intuitive use and concern for patient outcomes. Overall, these themes provide evidence that nurses strongly prefer a more usable intravenous smart pump interface that integrates safeguards to efficiently improve patient outcomes. Findings support the need for intravenous smart pump technology to be developed with an intuitive interface that decreases the level of cognitive demand and will lead to improved patient safety.
... [14][15][16][17] Despite an increasing focus in healthcare on patient safety and quality of care, and improvements in technology, medication errors and usability issues with IVSPs continue to be a significant patient safety issue. [18][19][20] ...
... [21][22][23] Lack of compliance with manual setup requirements leads to unpredictable, and largely undetectable, variation in flow rates of fluid and medication delivery, especially with secondary infusions. [20][21][22] As a result, the 2020 Institute for Safe Medication Practices guidelines for optimising safe implementation and use of smart infusion pumps 21 recommend the use of systems for secondary infusion that does not require head-height differentials. 24 In contrast, pneumatic-driven systems use internal flow control valves to independently regulate both primary and secondary flow rates, which function to move fluids forward for infusion into the patient. ...
... Subscale raw scores can be used individually or in combination to assess participant's cognitive experiences during task performance. 25 Each subscale uses an interval scale ranging from low (0) to high (20) and subscales can be summed to create combined scores, with higher scores indicating higher perceived cognitive workload. The NASA-TLX has been used widely in healthcare and for usability testing in the simulated environment and is reliable and valid for cognitive workload, with a reported testretest reliability of 0.77 and a high concurrent validity (0.73-0.79). ...
Objective
To describe and compare safety and usability between a peristaltic large-volume intravenous smart pump (IVSP) and a novel pneumatic large-volume IVSP during clinical use.
Methods
A prospective, comparative study was conducted in a large, tertiary hospital in the southeastern USA. Safety and usability were measured by observation during medication administration (medication administration error, interruptions, programming time), dose error reduction system (DERS) compliance, end-user surveys and compliance with manufacturer setup requirements. Study implementation began on a small pilot unit for 1 month, followed by data collection on the study unit over 2 months.
Results
For the observed medication administrations (N=158): 79 peristaltic (36 primary; 43 secondary) and 79 pneumatic (42 primary; 37 secondary), use of the peristaltic IVSP was associated with significantly (p<0.05) higher medication administration errors and programming time (11.9 s) and a significantly higher number of interruptions during programming.
DERS compliance was significantly less (p<0.001) with the peristaltic (75.9%) as compared with the pneumatic IVSP (99.8%). Programming workload (National Aeronautics and Space Administration Task Load Index) was significantly (p=0.004) higher with peristaltic versus pneumatic IVSP, and the usability (System Usability Scale) was significantly (p=0.007) lower with peristaltic versus pneumatic IVSP. There was a 0% compliance with peristaltic secondary setup requirements in 43 observed infusions.
Conclusions
Though nurses had a high level of experience with the peristaltic IVSP, results of this study support that the pneumatic IVSP was easier to use and associated with fewer errors and deviations from safe practices as compared with the peristaltic IVSP.
... Ideally, medications should infuse independently through intravenous tubing without joining any other infusion prior to entering the patient's bloodstream. 27 This is ideal regardless of the tubing length or medication rate because fluids are incompressible within the single drug volume and therefore a rate adjustment programmed in the IVSP will be accompanied by an immediate adjustment at the patient's bloodstream. This situation may be impractical in critical care because of the need for multiple life-critical infusions. ...
The COVID-19 pandemic has stretched hospitals to capacity with highly contagious patients. Acute care hospitals around the world have needed to develop ways to conserve dwindling supplies of personal protective equipment (PPE) while front-line clinicians struggle to reduce risk of exposure. By placing intravenous smart pumps (IVSP) outside patient rooms, nurses can more quickly attend to alarms, rate adjustments and bag changes with reduced personal risk and without the delay of donning necessary PPE to enter the room. The lengthy tubing required to place IVSP outside of patient rooms comes with important clinical implications which increase the risk to patient safety for the already error-prone intravenous medication administration process. This article focuses on the implications of increasing medication dead volume as intravenous tubing lengths increase. The use of extended intravenous tubing will lead to higher medication volumes held in the tubing which comes with significant safety implications related to unintended alterations in drug delivery. Safe intravenous medication administration is a collaborative responsibility across the team of nurses, pharmacists and ordering providers. This article discusses the importance and safety implications for each role when dead volume is increased due to IVSP placement outside of patient rooms during the COVID-19 pandemic.
... The most commonly used method for secondary administration requires the primary continuous infusion to pause during the secondary infusion, then resume automatically after the secondary infusion is complete. 1,[11][12][13] The secondary infusion delivery method typically is used for administration of antibiotics and electrolyte replacement therapy. 14 Research has identified secondary medication infusions as particularly error prone. ...
... 14 Research has identified secondary medication infusions as particularly error prone. 12,14 Both the setup and usability of most IV smart pump systems are complex, vary among different IV smart pump types, and have numerous associated failure modes that are not easily detected at the point of care. 12 The majority of secondary medications are infused using the "head height differential" method, which requires a differential between the top of the fluid level in the primary and secondary fluid containers. ...
... 12,14 Both the setup and usability of most IV smart pump systems are complex, vary among different IV smart pump types, and have numerous associated failure modes that are not easily detected at the point of care. 12 The majority of secondary medications are infused using the "head height differential" method, which requires a differential between the top of the fluid level in the primary and secondary fluid containers. These differentials generate the hydrostatic pressure required to close the primary tubing back-check valve and facilitate accurate secondary medication infusion ( Figure 1). ...
Objective
The primary purpose of this research was to describe nurse and pharmacist knowledge of setup requirements for intravenous (IV) smart pumps that require head height differentials for accurate fluid flow.
Methods
A secondary analysis of anonymous electronic survey data using a database of prerecruited clinicians was conducted. A survey was sent by email to 173 pharmacists and 960 nurses. The response rate for pharmacists was 58% (100 of 173), and the response rate for nurses was 52% (500 of 960). After removing respondents who did not provide direct care and who did not use a head height differential IV infusion system, the final sample for analysis was 186 nurses and 25 pharmacists.
Results
Overall, less than one-half of respondents (40%) were aware that manufacturer guidelines for positioning the primary infusion bag relative to the infusion pump were available. Slightly more (49.5%) were aware of the required head height differentials for secondary infusion. Only five respondents selected the correct primary head height, eight respondents selected the correct secondary head height, and one respondent selected both the correct primary and secondary head heights.
Conclusion
The results of this study identify a substantial lack of knowledge among frontline clinicians regarding manufacturer recommendations for accurate IV administration of primary and secondary infusions for head height differential infusion systems. Both increased clinician education and innovative technology solutions are needed to improve IV smart pump safety and usability.
... Of the work that has been done, weight-based infusions, secondary infusions, and IV boluses have been identified as particularly high risk and error prone. 2,16 These IV medication administration tasks place additional cognitive demands on users, are not well standardized within hospital protocols, vary among IV smart pump user interfaces, and have associated failure modes that are not easily detected. 16 Unfortunately, available data comparing the workflow and usability for the user interfaces of different IV smart pump types are scarce. ...
... 2,16 These IV medication administration tasks place additional cognitive demands on users, are not well standardized within hospital protocols, vary among IV smart pump user interfaces, and have associated failure modes that are not easily detected. 16 Unfortunately, available data comparing the workflow and usability for the user interfaces of different IV smart pump types are scarce. 3,16,17 As a result, limited empiric data exist about what can and should be required by manufacturers to help make their products safer and easier to use. ...
... 16 Unfortunately, available data comparing the workflow and usability for the user interfaces of different IV smart pump types are scarce. 3,16,17 As a result, limited empiric data exist about what can and should be required by manufacturers to help make their products safer and easier to use. ...
This descriptive observational study was conducted to increase understanding of medication administration practices during actual clinical use between 2 commonly used, different types of intravenous (IV) smart pumps. Compliance with manufacturer-recommended setup requirements for both primary and secondary infusions and secondary medication administration delay was compared between a head-height differential system and a cassette system. A total of 301 medication administration observations were included in this study: 102 (34%) for the linear peristaltic IV smart pump (medical-surgical: N = 51; critical care: N = 51) and 199 (66%) for the cassette pump (medical-surgical: N = 88; critical care: N = 111). Results found a 0% compliance for primary line setup and 84% compliance for secondary line setup and 1 omitted medication due to a closed clamp with the linear peristaltic system. For the cassette system, there are no head-height requirements. Two roller clamps were found to be in the closed position on initiation of the secondary infusion, but the clinician was alerted by an alarm, so no medication delays occurred. These findings support that the current system requirements for flow rate accuracy using head-height differential systems are difficult to achieve consistently at the point of care. There is a need for additional human factor designed technology to replace manual actions to improve the process of care for nurses and the safety of care for patients.
... The most commonly used method for secondary administration requires the primary continuous infusion to pause during the secondary infusion, then resume automatically after the secondary infusion is complete. 1,[11][12][13] The secondary infusion delivery method typically is used for administration of antibiotics and electrolyte replacement therapy. 14 Research has identified secondary medication infusions as particularly error prone. ...
... 14 Research has identified secondary medication infusions as particularly error prone. 12,14 Both the setup and usability of most IV smart pump systems are complex, vary among different IV smart pump types, and have numerous associated failure modes that are not easily detected at the point of care. 12 The majority of secondary medications are infused using the "head height differential" method, which requires a differential between the top of the fluid level in the primary and secondary fluid containers. ...
... 12,14 Both the setup and usability of most IV smart pump systems are complex, vary among different IV smart pump types, and have numerous associated failure modes that are not easily detected at the point of care. 12 The majority of secondary medications are infused using the "head height differential" method, which requires a differential between the top of the fluid level in the primary and secondary fluid containers. These differentials generate the hydrostatic pressure required to close the primary tubing back-check valve and facilitate accurate secondary medication infusion ( Figure 1). ...
... Even in wellequipped hospital settings (e.g. intensive care units) this can be a complex undertaking, with numerous potential correlated patient safety risks such as separate drugs running at incorrect infusion rates and required medications being connected to the infusion system but not administered to the patient [3]. However, there are scenarios outside of a sophisticated medical facility environment where the availability of specialised equipment may be limited, or many patients must be attended to within a short schedule. ...
Background
There are scenarios where pre-mixing and infusing analgesic and anaesthetic agents as a single intravenous (IV) solution is highly desirable; however, it is important to ensure the agents are compatible when mixed. As such, the long-term stability of a remifentanil-propofol mixture, and means of improving this, were assessed across a range of remifentanil concentrations, diluents, and time points.
Methods
Remifentanil was reconstituted with ultrapure water, 0.9% saline, 20% saline, or 8.4% sodium bicarbonate solution (the latter two chosen for their pH characteristics, rather than their use in pharmaceutical reconstitution) and then mixed with propofol (1%) or further diluted with water to derive concentrations of 10–50 μg mL− 1. Remifentanil and propofol concentrations were determined initially and then periodically for up to 24 h using high performance liquid chromatography (HPLC). Mass spectrometry (MS) was used to detect degradation products in solutions containing 30 μg mL− 1 of remifentanil. Statistical analysis was performed using ANOVA and Student’s t-test, with a significance value of 0.05.
Results
Isolated remifentanil (pH < 4) and propofol (pH 7.35) did not degrade significantly when reconstituted with water or saline solution over 24 h, while remifentanil reconstituted with sodium bicarbonate degraded significantly (P < 0.001, pH 8.65). Mixing with propofol substantially increased the pH of the mixture and resulted in significant remifentanil degradation for all reconstitution solutions used, while propofol remained stable (pH 6.50). The amount of degradation product detected in samples containing isolated remifentanil and a mixture of the drugs was proportional to the remifentanil degradation observed.
Conclusions
Remifentanil stability is affected by both the reconstitution solution used and when mixed with propofol, with pH appearing to be a contributing factor to degradation. If the pH of the solution and concentration of remifentanil are correctly controlled, e.g. through the use of a more acidic diluent, an admixture of remifentanil and propofol may be useful clinically.
