Smart IV Pumps vs.

Standard IV Pumps
By: Lab group A

PICOT Question
PPT edited by: Alyssa Mattus

In adult hospitalized patients (P), does the

use of smart pumps (I) decrease the
number of med administration errors (O)
versus the use of standard pumps (C) over
10 weeks (T)?

Smart Pumps vs. Standard

Pumps
By: Alyssa Mattus

According to the FDA, "smart infusion

pumps have safety features that standard
pumps lack.
Alerts for adverse drug interaction, hard
and soft limits, and a drug library.
Soft limits can be overridden and the
medication can still be infused without
changing the smart pump settings.
Hard limits are for if the dose is out of the
institution-determined safe range. Meds
will not be infused without setting changes.
Food and Drug Administration. (2014)

Summary of Current Practice

By: Clay Sensibaugh

What are Smart Pumps?

Programmable pumps that deliver
parenteral infusions and are capable of
alerting the user that the programmed
setting is outside the institutions set
standards
Not a new concept but technological
breakthroughs have allowed for the
addition of softwares.
Have helped drive safe practice within
healthcare facilities.
Health Management Academy. (2010)

EEPROM
In the late 90s, there was a technological
breakthrough called electronically erasable
programmable read-only memory
(EEPROM)
Safety software that allowed for pumps to
be tailored to each specific floor and
patient.
Produced a warning or prevented infusion
if programmed settings were outside the
institutions criteria.

(Vanderveen, 2014).

DERS
Dose Error Reduction System is a program that cross
references the configured setting against the preset
parameters
Soft stop: notifies the user that the programmed setting is
outside of the anticipated setting for that medication; can
be overridden
Hard stop: notification that states that programmed
setting is outside of the safe range; can not be overridden
Upper Limit: Highest dose that can be infused while still
being considered a safe dose
Lower Limit: Lowest dose that can be administered

Health Management Academy. (2010)

Institution for Safe Medication Practices (ISMP) (2009).

To Err is Human
Released in 2000 by the Institute of
Medicine (IOM)
Brought medication safety to center stage.
Their strategy for improvement?
Establish a national focus
Mandatory reporting system
Raise standards and expectations
Implement new safety systems

Adoption of the Smart Pump

National:
81% of all hospitals, up from 32% in 2005
100% of hospitals with more than 600 beds, up
from 84% in 2009
67% in hospitals with fewer than 50 beds, up
from 41% in 2009
Tucson:
6 core hospitals
4/6 use smart pumps, the exceptions
include the two carondelet hospitals, St.
Joes and St. Marys (just started to
implement them on high acuity floors).

Blank (2015).

Behind the drivers seat of safe

practice
Intravenous (IV) medication administration
90% of all hospitalized patients receive
IV meds
Most difficult procedure that RNs
perform
Medication administration accounts for
anywhere from 27% to 65% of an RNs
time.
Errors occur 67% of the time; account
for 61% of all medication errors;
responsible for 54% of all adverse drug
reactions
Eskew et al. (2002)
Hendrich et al, (2008)
ASHP (2008)
Kaushal et al (2001).

Improving patient safety

In a 2010 study conducted by the Health
Management Academy, the adoption of
smart pumps within Americas leading
healthcare systems found that:
Medication errors were reduced by 37%
ADRs were reduced by 33%
Healthcare personnel satisfaction
increased 27%
Workflow and Productivity improved
16%
Patient satisfaction improved by 8%
HMA (2010).

Synopsis of Current Literature

Research Findings
By: Alyssa Hall

Smart Infusion Pumps Reduce Intravenous Medication

Administration Errors at an Australian Teaching Hospital
In the period of 41 days
76 infusions recorded from IMED Gemini Volumetric non-smart
pump.
In the period of 21 days (20 months after introduction of Alaris smart
pump)
25 infusions were recorded from Alaris GP Volumetric smart pump
There was an overall 79 % reduction in drug infusion errors when
using the Alaris pump compared to the IMED Gemini

(Pang et al., 2011)

Automatic vs. Manual Changeovers of Norepinephrine

Infusion Pumps in Critically ill Adults
411 changeovers with patients receiving norepinephrine
for shock
193 changeovers in 18 patients used a manual quick
change technique
A MAP drop greater than 20% was found in 12.4 % of
patients
218 changeovers in 32 patients used an automatic smart
pump technique
A MAP drop greater than 20% was found in only 5.5% of
patients
(Greau et al., 2015)

Reducing the Risk of Harm of Intravenous Potassium in a

Haematology Setting

Pre intervention phase

Over a 12-month period consisted of 23 incident reports
Post intervention phase
Introduced safety systems including dose checks, pre-mixed
bags of potassium, and extensive clinician training with
introducing the smart pump infusion software
Over a 12-month period, there was a total of 9 incident reports
after implementation of safety systems

(Barras et al., 2014).

Intravenous Drug Infusion Safety Through Smart Pumps

Over a 6 month period
120 Plum A+ with Hospira MedNet software were used in
hospital units of oncology, rheumatology, and pediatric
oncology
70,000 infusions were studied for error with alert warnings of
unsafe doses/rates
A total of 756 errors were avoided during this study as
recorded by reports of IV medication administration that the
smart pump software captured

(Gmez-Bazara et al., 2014)

Analysis of Event Logs from Syringe Pumps: To Assess

Possible Effects of Syringe Pumps on Safety
A total of 7884 patient treatment days
133,601 infusion starts and 1063 dose rate alerts were
evaluated
717 cases were thought to lead to potentially harmful effects
of overdosing
66 of these cases, the pumps were re-programmed to the
safe range given by software

(Kastrup et al., 2012)

Enhancing Patient Safety with Intelligent Intravenous

Infusion Devices: Experience in a Specialty Cardiac
Hospital

Over a 9-month period

644 infusions had dosing parameters outside normal ranges
150 were soft limits and 494 were hard limits
The 494 critical catches saved $5,635,000 over the 9 month
period and $7,513,333 annually

(Wood & Burnette, 2012)

Strengths and Limitations of our Research

Articles
Article Name

Analysis of Event Logs from

Syringe Pumps: A Retrospective Pilot
Study to Assess Possible Effects of
Syringe Pumps on Safety in a
University Hospital Critical Care Unit in
Germany

By: Alysa Hackett

Strengths

Weaknesses

The study had a large sample

size and 133,601 infusion starts
were evaluated.

Nurses Risk Without Using Smart

Pumps

Enhancing Patient Safety with

Intelligent Intravenous Infusion
Devices: Experience in a Specialty
Cardiac Hospital

- The opinions presented were

obtained from reputable sources, as
they were either the reports of expert
committees or from authorities.

- This article included evidence from

the opinions of authorities and/or
reports from expert committees.
Although opinions are important, they
do not hold much weight compared to
experiments.

This article included report from

all the nurses within the St.
Vincents Heart Center over a
nine-month period. This articles
sample size was much larger than
most.

See EBP Table of Evidence

The study conducted did not

include a diverse population. The
study was only tested in a single
cardiac surgery ICU of a single
hospital. This explains the large
amount for started and infusions
and alerts for cardiovascular
medications
The syringe pumps were not
connected to the electronic chart;
therefore, there is no information
regarding the direct clinical impact
of the dose rate alerts.

The study is a quasi-experiment;

therefore, it lacks randomization.

Automatic versus manual

changeovers of norepinephrine
infusion pumps in critically ill adults:
a prospective controlled study

The design of the study limited

the risk for possible bias.
Most patients were randomized.
Although the study did not
assess the patient outcomes
after the use of smart pumps, the
study did in fact investigate
hemodynamic stability with each
patient. This is the first step in
determining the use of smart
pumps in improving patient
outcome.

The general applicability of the

results may be reduced as a
result of the studys singlecenter design.
In this study, the nurses had to
manually calculate the amount of
norepinephrine in the syringe for
each patient that they had.

Intravenous drug infusion safety

through smart pumps

- This study had a diverse population.

The study included nurses taking care of
adult patients in an oncology unit, a
hematology unit and a rheumatology
unit, and pediatric patients in an
oncology unit

In this study, they only tested errors

on the Plum A+ pumps. This is a
limitation, as it does not show
errors in a variety of different
pumps.

Evaluation of Intravenous Medication

Errors with Smart Infusion Pumps in
an Academic Medical Center

The limitation of this study is that

the observations and evidence
presented were collected on a
single day.
The sample size was small as it
only included observations from
one day and only included the
nurses of 55 inpatients.
Because the study was a clinical
case report, a cause and effect
relationship cannot be determined.

The study was a compilation of

case reports. This allowed a more
in-depth understanding of why
errors were made.

Reducing the risk of harm from

intravenous potassium: A multifactorial approach in the haematology
setting.

Benefits of Smart Pumps for

Automated Changeovers of
Vasoactive Drug Infusion Pumps: A
Quasi- Experimental Study.

Smart Infusion Pumps Reduce

Intravenous Medication
Administration Errors at an
Australian Teaching Hospital

The study included data over 12

months. This is the longest

The study only included data

collected on incidents of
intravenous potassium.

A major strength of this article is

that they preformed two separate
testing periods of six months.
There was a large sample size,
1329 infusions were studied.

In this study, they only utilized

vasoactive drugs. This is not easily
applicable to the benefits of smart
pumps in general.

The study included nurses from a

variety of units. All nurses giving
IV medications to patients on the
general medical and surgical
wards, the intensive care unit,
recovery rooms, emergency
department, day oncology unit,
pediatric unit and maternity ward
in the Frankston Hospital of
Melbourne, Australia.

This study did not audit the actual

number of administration errors
that occurred before and after the
introduction of smart pumps.
The study was conducted from
8:30 to 5pm on weekday and did
not include weekends or public
holidays. This is problematic
because the chronogram created
by Fields et al. disclosed that the
most infusion related errors occur
from 3pm to 9pm an unexpected
peak at 6pm. This couldve
resulted in underestimation of the
number of errors that were
recorded.

Evidence-Based Recommendations
By: Tysen Haynie

Food and Drug Administration (FDA) Recommendations

1. Remember Safety!- Always perform the 5 (or 6) rights. Also,
perform double checks with another nurse for high risk medications.
2. Understand the Libraries- Understand what the facilitys set rates,
concentrations, dosages and other settings are on the pumps.
Understand hard and soft alerts and when the nurse can override and
when they shouldnt. These settings are there as a safety feature.
3. Check Doses- One of the most common mistakes made are dose
errors. (example: units/hr vs. ml/hr)
4. Overriding soft limits- Always check the alarms generated on soft
limits. (47.5ml/hr TPN vs 475 ml/hr. Nurse overrode the pump and
patient went hyperglycemic.)
U.S. Food and Drug Administration. (2014)

Evidence Based Practice Precautions

Make sure settings and programming are correct.

Double check with another clinician.
Use facility drug settings
Label infusion pumps if patient is receiving multiple
medications through pumps.
Use nursing judgement, don't rely on the pumps to warn
about issues. Monitor the patient.
Investigate and pay attention to alerts!
Reevaluate clinical libraries from time to time and match
them with standards of care and clinical policies.
Make sure staff is educated on how to use pumps properly.
Have facilitys policies and procedures readily available.

U.S. Food and Drug Administration. (2014)

Overall Application and Implementation to

Nursing Practice
By: Kristina Arnold
With assistance from Amanda Patterson and Alyssa Mattus

Prior to Implementation:
Assess readiness for change
Commitment to standardization
Culture of learning vs. culture of blame
Evaluate the current medication-use system and
compatibility to the new Smart pump technology
Ensure staff levels in IT and biomedical engineering are able
to support increased workload.

(Institute for Safe Medication,

2016)

1. Create Interdisciplinary Team (1 month)

Oversee process decisions, protocol development, drug library
revision requests, and maintenance.
The team should consist representatives from
Nursing
1 nurse from each unit (10 units total)
Pharmacy
2 Pharmacists (hospital-wide)
Physicians
1 physician per unit
Information Technology (IT) Department
1 IT representative per unit
Biomedical Engineering
2 biomedical engineers (hospital-wide)
(Institute for Safe Medication,
2016)

2. Decide on Brand of Smart Pumps (2-4 weeks)

Discuss benefits and drawbacks of different brands with
interdisciplinary team.
How many pumps?
How many channels?
Types of pumps needed
Estimated number of drug labels
Estimated number of clinical areas for use
Line utilization
3. Buy Smart Pumps and New Technology (2 weeks)
4. IT Technician Training (2 weeks)
Give the IT technicians time to learn how to use the smart
pumps
(Oncology Rounds, 2011)

5. Input Drug Library (2-6 months)

High Alert Medications with standard concentrations
Most common
Hard and soft limits
Policies in place to address changes and maintenance
6. Train charge nurses
Experts or super-users on the smart pump technology
Help assist nurses on the floor with new technology
7. Train Nursing Staff (8 weeks)
Simulations
Soft and hard limits
12 hour training session
Nurses will be paid overtime
(Reston, 2013)
(Institute for Safe Medication, 2016)

8. Begin 10 week Trial (10 weeks)

Hospital-wide
Help from vendor during the first two weeks
Charge nurses available to help the floor nurses during
full 10 weeks
9. Complete Error Analysis (1-2 weeks)
Compare errors during trial period to the errors during
the 10 weeks prior to implementation
10. Ongoing Evaluation of Implementation
Quarterly

(Phelps, 2011)
(Vanderveen, T. & Husch, M, 2015)

Cost Analysis
By: Amanda Patterson
With assistance from Kristina Arnold and Alyssa Mattus

449 hospital beds at St. Joseph's Hospital

Smart pumps
$2,184 - $6,685 each
Need 1-2 pumps on average per bed (patient)
Training
the average nurse in Tucson makes $30 per hour and will be
paid time-and-half for the extra day he/she trains ($45)
Training hours: one 12 hour shift per nurse
St. Joe's employs approximately 250 nurses
Hiring 1 more pharmacist
$120,000 (salary for first year)
**These figures and total costs to be presented on the next slide are
consistent with other cited smart pump hospital implementation
costs Finance, 2016).
(Healthcare
St. Joe's taken from U.S. and World Report Health News, 2016.
Payscale Inc, 2016.
Career Trends, 2016.

Smart Pump A

Smart Pump B

Total cost of implementation if we buy

smart pump A (comes with two
channels):
Pump:
449 beds x $6,865 x 1 pump
=$3,082,385
Training:
$45 x 12 hr x 250 nurses=
$135,000
Pharmacist:
$120,000
TOTAL: $3,337,385
**Any future additional channels:
$1,000 (average)

(Medical Equipment Incorporated, 2016)

(Biomedix Medical Inc, 2016).
(Institute for Safe Medication Practices, 2016).
(Healthcare Finance, 2016)

Total cost of implementation if we buy

smart pump B (comes with one
chamber)
Pump:
449 beds x $2,184 x 2 pumps
=$1,961,232
Training:
$45 x 12 hr x 250 nurses=
$135,000
Pharmacist:
$120,000
TOTAL: $2,216,232
**Any future additional pumps:
$2,184

So why is this worth it?

The IOM reports that more than 1.5 million preventable
ADEs occur annually
This results in a total of $4 billion in healthcare costs
each year
Each ADE adds about $8,750 to a hospital stay
The Institute for Healthcare Improvement suggests using
Smart pumps to reduce ADE's related to infusions
**To be discussed further in risks vs. benefits section

Food and Drug Administration, 2014

Institute for Healthcare Improvement, 2016
U.S. Department of Health and Human Services, 2014

Risks vs. Benefits

By: Kelli Kirschner

Risks of Using Smart Pumps

Added cost to hospital
Depending on the type of smart pump the cost of implementation
could range from $2,216,232- $3,337,385

Inaccurate data entry (patient name, correct medication, patient

weight, etc.)
This can lead to an inadvertent medication error

Safety alerts overrideable

If nurses do not adequately understand the alerts, they can
override them which negates the safety measures set in place
by the smart pump

(Kirkbride & Vermace, 2011)

(Institute for Safe Medication Practices, 2016)

Benefits of Using Smart Pumps

Drug library
Allows for organizations to develop dosing guidelines that meet the
specific needs of their patient population (location, acuity, weight, etc.)
Smart pumps can check manual drug calculation and ensure that the
dosing formula is the correct one for the drug (mcg/kg/hr, mcg/kg/min,
etc.)

Safety alerts
Clinical advisories and dosing limits

Selection of drugs based on therapeutic indication

Bolus vs. maintenance fluid vs. continuous infusion

Reduction of medication errors

Smart pumps record the actions nurses take so they can be
analyzed to improve the quality and safety of patient care
Reduction of medication errors decreases patient's hospital stay
time which reduces cost
(Kirkbride & Vermace, 2011)
(Institute for Safe Medication Practices, 2016)

Evaluation
By: Brittany Dollarhide

All frequently-used medications will be entered into the

drug list at the end of the 6 months.
Frequently-used medications will be determined per
unit.
At least 95% of all floor nurses will be able to
demonstrate proper setup of a basic IV rate (ml/hr).
Nurses who arent proficient yet, can receive help
from smart-users or charge nurses.
By the end of the 10-week trial, there will be at least 98%
compliance with the use of smart pumps.
100% compliance may be unrealistic, since some
drugs may not be entered into the drug list.

Evaluation Cont.
At least a 50% reduction in drug administration errors will
be observed in the trial period, when compared to the 10
weeks prior to implementation.
Prior to implementation, medication errors may have
occurred, however, some medication errors may have
gone unrecognized.
Analyze internal data, to establish hard and soft limits
during quarterly evaluations.
Adjusting hard and soft limits based on individual
hospital use may prevent alarm fatigue

PICOT Question
PPT edited by: Alyssa Mattus

In adult hospitalized patients (P), does the

use of smart pumps (I) decrease the
number of med administration errors (O)
versus the use of standard pumps (C) over
10 weeks (T)?

Smart pumps improve patient safety, but

opportunity for errors still remain.
Studies have concluded that smart pumps have lead to
Reduced drug errors
Improved nurse and patient satisfaction
Improved personnel productivity
Best practice recommendations
5 rights of medication administration
Nurses judgement
Labeling of tubing
Need for education
Dont override soft stops

Implementation
Assess readiness for change
Staffing needs
Purchasing of pumps and software
Common drugs entered within 6 months
Staff training
One 12 hour training session at overtime pay
Implementation of a 10 week pilot session
95% proficiency
98% compliance
Data analysis
Medication error reduction by 25%
Quarterly evaluation on a continual basis

The Million Dollar Question

Option 1: Alaris
3,337,385
Option 2: Plum A+
2,216,232
Risks
Added costs of implementation and staffing
Inaccurate data entry (pt. name, drug dose)
Overriding safety stops, key bounce, alarm fatigue
Benefits
Reduced med errors
Increased patient satisfaction

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