The Empty Bag
Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate. Chris Vincent, PhD, of the University College London, reviews human factors engineering approaches that can reduce errors related to intravenous medications.
The Empty Bag
TableTable. Infusing Patients Safely: Thirteen Priority Issues From the AAMI/FDA Infusion Device Summit Report (1) © 2010 Association for the Advancement of Medical Instrumentation. Reprinted with permission.
|Standardize systems and processes for reporting, aggregating, and analyzing infusion device incidents.|
|Improve the integration of infusion devices with information systems and drug libraries.|
|Mitigate use errors with infusion devices.|
|Improve management of multiple infusions.|
|Reconcile challenges and differences in the use environments of infusion devices.|
BoxBox: Glossary of Terms Relating to IV Therapy.
|Ambulatory infusion device: A portable or wearable infusion device. |
Continuous infusion: Delivery of a medicine and/or fluid (within a large volume of solution) at a constant rate over a prescribed period.
DERS: (Dose Error Reduction Software/System): Technology designed to reduce the incidence of IV medication error. Also called Drug Error Reduction Software/System.
Double pumping: Use of two pumps simultaneously. This occurs when there is a need to change infusions without interrupting the flow.
Free-flow: Rapid and uncontrolled delivery of fluid into a patient's body.
Gravity infusion: A pump is not used; gravity moves the fluid through the IV tubing into the patient's vein under control of a roller clamp.
Infusion pump: A medical device used to deliver fluids into a patient's body in a controlled manner.
Intermittent infusion: A small volume is infused over a short period of time.
Multiple [line] infusion: Delivery of multiple solutions to a single patient through one or more catheters.
Multiple channel infusion device: Solutions are delivered from multiple reservoirs at multiple rates.
Piggyback infusion: [used interchangeably with secondary infusion]: The drug infusion is administered via the pathway of a primary solution. NB: It is typical for the primary infusion to be paused while the piggyback/secondary infusion occurs.
Simultaneous infusion: The drug infusion is administered as a secondary infusion run concurrently with the primary infusion.
Smart pump: An infusion device that is equipped with safety features, e.g., alerts when the pump's parameters fall outside of safety limits.
Syringe driver: Type of infusion device—a moveable piston controls fluid delivery.