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Difficulty Using Smart Pump Logs to Recreate a Patient Safety Event: Case Study and Considerations for Pump
Andrew A M Ibey1, Derek Andrews2, Barb Ferreira3
1Department of Biomedical Engineering, Providence Healthcare, Vancouver General Hospital, 855 West 12th Ave, Vancouver, BC, V5Z 1M9, Canada. aibey@providencehealth.bc.ca.
Drug Safety - Case Reports
|October 18, 2016
Summary
A smart infusion pump communication error, caused by dirty connectors, led to a patient's cardiac arrest. Troubleshooting the alarm exacerbated the issue, highlighting challenges in reconstructing patient safety events from pump data.
Area of Science:
- Medical Device Safety
- Clinical Engineering
- Patient Care Technology
Background:
- Smart infusion pumps are critical for medication delivery in critical care settings.
- A communication error alarm on an infusion pump presented a challenge for clinical staff.
- The case highlights the potential for technology-related failures to impact patient outcomes.
Purpose of the Study:
- To detail a patient safety event involving an infusion pump malfunction.
- To investigate the root cause of an infusion pump communication error.
- To assess the limitations of smart pump logs for incident reconstruction.
Main Methods:
- Case study analysis of a patient experiencing a gastrointestinal bleed and myocardial infarction.
- Investigation of smart pump logs, continuous quality improvement (CQI) data, and drug order entry system.
- Examination of inter-unit interface (IUI) connectors for physical anomalies.
Main Results:
- A "communication error" alarm was traced to dirty IUI connectors between the PC unit (PCU) and pump modules.
- Nurse's troubleshooting attempts to resolve the alarm inadvertently interrupted dopamine infusion, leading to patient decompensation and cardiac arrest.
- Smart pump event logs and software were found to be inadequate for retrospective incident investigation.
Conclusions:
- Dirty connectors on infusion pumps can cause critical errors impacting patient safety.
- Current smart pump data systems present significant challenges for reconstructing patient safety events.
- Recommendations are made for improved nursing protocols and enhanced smart pump design for greater patient safety.
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