Reduction in Prostacyclin Infusion Errors Following a Comprehensive Multidisciplinary Process Transformation for...

Area of Science:

• Patient Safety
• Healthcare Quality Improvement
• Pharmaceutical Infusion Therapy

Background:

• Parenteral prostacyclin infusions are critical treatments.
• An increase in errors was observed with the MedFusion 3500 syringe pump.
• A comprehensive continuous process improvement (CPI) project was initiated to enhance safety.

Purpose of the Study:

• To describe the methodology of a CPI project focused on prostacyclin infusion safety.
• To assess the impact of the CPI project on the incidence of infusion errors.

Main Methods:

• A multidisciplinary team implemented CPI interventions targeting ordering, preparation, dispensing, and administration phases.
• Interventions included EHR standardization, optimizing syringe pump features, developing a job aid, and bedside education.
• A retrospective analysis compared error rates before and after CPI implementation (January 2013-December 2023).

Main Results:

• Pre-CPI error rate was 1.8 errors per 100 patient days (27 errors/1471 days).
• Post-CPI error rate decreased to 0.3 errors per 100 patient days (5 errors/1512 days).
• Post-CPI, patients started infusions at a younger age, with a longer average infusion duration.

Conclusions:

• The comprehensive CPI project effectively reduced errors associated with prostacyclin infusions on the MedFusion pump.
• Sustained efforts ensured the maintenance of low error rates, improving patient safety.