Unintended Patient Safety Risks Due to Wireless Smart Infusion Pump Library Update Delays

Abstract

Objective Our previous study showed that the issue of drug library update delays on wireless intravenous (IV) infusion pumps of one major vendor was widespread and significant. However, the impact of such a delay was unclear. The objective of this study was to quantify the impact of pump library update delays on patient safety in terms of missed and false infusion programming alerts. Methods The study data sets included infusion logs and drug libraries from three hospitals of one health system from January 2015 to December 2016. We identified limit setting changes of any two consecutive drug library versions. We quantified the impact of using outdated drug limit settings by missed and false infusion programming alerts. Results Twenty-five updates of the drug library were released within the health system during the 2-year period with an average interval of 28.8 days. After a new library version was issued, it took at least 6 days for 50% of all pumps to become up-to-date and 15 days or more to reach 80%. All three hospitals had at least 16% of all IV infusions programmed with outdated libraries. This resulted in 18%, 24.4%, and 27% of false alerts in the three hospitals, respectively. We identified two cases of missed alert infusions of high-risk medications, propofol, and potassium chloride, which could have negatively impacted patient safety. Conclusions These findings support our assumption that potential serious harm can happen when IV infusions are administered with outdated drug limit settings due to delays in drug library updates on the pump.

Extending tubing to place intravenous smart pumps outside of patient rooms during COVID-19: an innovation that increases medication dead volume and risk to patients

“…IVSP library update dissemination is not instantaneous; indeed, only about 80% of hospital IVSP have been found to be updated within 10 days of a new wireless update release. 32 These delays are likely to be greater when, due to COVID-19, a higher proportion of IVSP are continuously in use, and rarely power cycled, or when rental IVSP are used to supplement a hospital's fleet. When a previous version of a drug library and dose error reduction system remain installed on an IVSP, errors can occur due to obsolete dose limit settings, drug concentration updates, missed alerts and false alerts.…”

“…When a previous version of a drug library and dose error reduction system remain installed on an IVSP, errors can occur due to obsolete dose limit settings, drug concentration updates, missed alerts and false alerts. 32 As updates are released which are relevant to remote intravenous medication infusion, it is important that the updates be installed in all IVSP as quickly as possible and monitored using a verification process.…”

Quantifying the Impact of Infusion Alerts and Alarms on Nursing Workflows: A Retrospective Analysis

“…1 To understand the varying impact of smart infusion pumps on patient care, many studies have explored the care provider and work system perspective, for example, technology design, usability, and sociotechnical system integration. [2][3][4][5][6][7][8][9][10][11][12][13][14][15] Although some investigators have shown that automated smart infusion pumps improve perceived safety, workflows, and workloads compared with manual pumps, many studies highlighted concerns of the technology's impact on use errors, suitability across the wide range of use environments, and workflow efficiencies. 16 Moreover, even though smart infusion pumps have the technological capabilities to reduce the incidence of adverse drug event and medication administration errors, 17 they could also be a potential source of patient harm.…”

Stakeholder perceptions of smart infusion pumps and drug library updates: A multisite, interdisciplinary study

“…27 Although a smart pump can still function normally without an updated drug library, there may be negative consequences for not using the most current library. 28 Through collaboration between ICPS and researchers at Purdue University, gaps were identified in the process for ensuring timely smart pump drug library updates. In a recent study of infusion pump update delays using infusion alert data from 2015-2016, substantial drug library update delays were observed among all but 1 of 12 health systems (including 5 ICPS member systems), with median delays ranging from 22 to 192 days.…”