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

Owing to a rise in potentially serious errors with parenteral prostacyclin infusions associated with using an unfamiliar MedFusion 3500 syringe pump (MedFusion), we implemented a comprehensive continuous process improvement (CPI) project to increase the overall safety of prostacyclins. The objective of this report was to describe the project's methodology and assess its impact on the number of errors.

A multidisciplinary team targeted 3 error-prone phases of prostacyclin delivery-ordering, preparation and dispensing, and administration-with CPI between January and October 2019. CPI involved standardizing the ordering process in the electronic health record, fully using the safety features of the MedFusion syringe pump, developing an electronically accessible job aid, and providing ongoing bedside education. A retrospective analysis of errors related to prostacyclin infusion was conducted from January 2013 to December 2023, covering both periods before and after CPI completion.

Before CPI, there were 1471 days of prostacyclins and 27 errors, or 1.8 per 100 patient days. After CPI, there were 1512 days of prostacyclins and 5 errors, or 0.3 per 100 patient days. After CPI, the age at start of infusion was lower, and the average length of infusion increased.

Our multidisciplinary comprehensive CPI decreased errors associated with prostacyclin infusions on the MedFusion pump, and continuous efforts have maintained low error rates.