NDLI: Dose error reduction software in medication safety risk management – optimising the smart infusion pump dosing limits in neonatal intensive care unit prior to implementation

Content Provider	Springer Nature : BioMed Central
Author	Kuitunen, Sini Kärkkäinen, Krista Linden-Lahti, Carita Schepel, Lotta Holmström, Anna-Riia
Abstract	Background Smart infusion pumps with dose error reduction software can be used to prevent harmful medication errors. The aim of this study was to develop a method for defining and assessing optimal dosing limits in a neonatal intensive care unit’s smart infusion pump drug library by using simulation-type test cases developed based on medication error reports. Methods This mixed-methods study applied both qualitative and quantitative methods. First, wrong infusion rate-related medication errors reported in the neonatal intensive care unit during 2018–2019 were explored by quantitative descriptive analysis and qualitative content analysis to identify the error mechanisms. The researchers developed simulation-type test cases with potential errors, and a literature-based calculation formula was used to set upper soft limits to the drug library. The limits were evaluated by conducting programming of pumps without errors and with potential errors for two imaginary test patients (1 kg and 3.5 kg). Results Of all medication errors reported in the neonatal intensive care unit, 3.5% (n = 21/601) involved an error or near-miss related to wrong infusion rate. Based on the identified error mechanisms, 2-, 5-, and 10-fold infusion rates, as well as mix-ups between infusion rates of different drugs, were established as test cases. When conducting the pump programming for the test cases (n = 226), no alerts were triggered with infusion rates responding to the usual dosages (n = 32). 73% (n = 70/96) of the erroneous 2-, 5-, and 10-fold infusion rates caused an alert. Mix-ups between infusion rates triggered an alert only in 24% (n = 24/98) of the test cases. Conclusions Simulation-type test cases can be applied to assess the appropriateness of dosing limits within the neonatal intensive care unit’s drug library. In developing the test cases, combining hospital’s medication error data to other prospective data collection methods is recommended to gain a comprehensive understanding on mechanisms of wrong infusion rate errors. After drug library implementation, the alert log data and drug library compliance should be studied to verify suitability of dosing limits.
Related Links	https://bmcpediatr.biomedcentral.com/counter/pdf/10.1186/s12887-022-03183-8.pdf
Ending Page	11
Page Count	11
Starting Page	1
File Format	HTM / HTML
ISSN	14712431
DOI	10.1186/s12887-022-03183-8
Journal	BMC Pediatrics
Issue Number	1
Volume Number	22
Language	English
Publisher	BioMed Central
Publisher Date	2022-03-08
Access Restriction	Open
Subject Keyword	Pediatrics Internal Medicine Dose error reduction software Error reporting High-alert medication Medication error Medication safety Neonatal intensive care unit Proactive risk management Smart infusion pump
Content Type	Text
Resource Type	Article
Subject	Pediatrics, Perinatology and Child Health
Journal Impact Factor	2/2023
5-Year Journal Impact Factor	2.4/2023

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1	Ministry of Education (GoI), Department of Higher Education	Sanctioning Authority	https://www.education.gov.in/ict-initiatives
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