Many organizations are implementing smart pumps (computerized intelligent infusion pumps) and nurses are the largest users of these health information technology devices. Smart pumps are recommended by safety experts to prevent errors in intravenous (IV) medication administration, particularly dosing errors, administration of high-alert medications, and with vulnerable populations such as newborns and children.
Smart pumps use a database of medications (drug library) and software (dose-error reduction rules) to provide information, or decision support, for the nurse. The nurse uses this information, along with clinical judgment, to proceed with the infusion. The drug library provides a profile, or a list of drugs and administration parameters customized by the organization for a specific patient population. The software processes the entered patient identification with the selected medication and triggers advisories (information and reminders about the drug, i.e., to assess a patient parameter) and alerts (warning that parameters entered or programmed by the nurse do not match the profile limits). Soft alerts are limits the nurse can override, whereas hard alerts require the nurse to reenter acceptable parameters. The pump event log collects data on bypass of the library, alerts and overrides, and errors prevented. Researchers consistently recommend that the most effective use of smart pumps involves interfaces to the electronic health record, barcode medication administration, and computerized provider order entry (Hertzel & Sousa, 2009).
Collectively, studies support the use of pumps in identifying and preventing IV medication errors (Hertzel & Sousa, 2009) but report that nurses often bypass the pump safety features and override pump alerts. The drug library should be used with all infusions because bypassing the library is bypassing all safety features. Research using observational audits found library usage rates as low as 28% of the time in a pediatric setting (Gavriloff, 2012) and research using pump event logs found bypass rates as high as 62% with insulin (Hertzel & Sousa). Research with pump event logs revealed that up to 12% of alerts are ignored and that overridden alerts were related to potential and preventable errors (Hertzel & Sousa, 2009).
The common reasons nurses give for bypassing the library and overriding alerts include library medication parameters that are not customized appropriately for their patient population, programming with the pump takes extra time, and too many alarms (Gavriloff, 2012; Hertzel & Sousa, 2009). Although focus groups of nurses reported positive views about smart pumps, they described challenges with the tubing, short battery life, pump weight, and volume inconsistencies with manufacturer bag overfill and additives (McAlearney et al., 2007). Nurses related unintended consequences and work-arounds including manually programming for extra volume, infusing secondary infusions on primary mode, and bypassing the library, especially with maintenance infusions.
A valuable resource for nurses using smart pumps is the Institute for Safe Medication Practices (ISMP, 2009) online publication "Proceedings from the ISMP Summit on the use of Smart Infusion Pumps: Guidelines for Safe Implementation and Use" available at http://www.ismp.org/tools/guidelines/smartpumps/printerversion.pdf. Recommendations for safe care include reviewing publications on successful performance improvement to improve current pump use such as the ISMP report and the Gavriloff (2012) article, using pump event logs to collect data for action, and exploring barriers to pump use.
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