Strategic Work-Arounds to Accommodate New Technology: The Case of Smart Pumps in Hospital Care

Objective: Computerized intravenous (IV) infusion pumps ("smart pumps") provide decision support to nurse end users at patients' bedsides during IV medication administration, but little is known about nurses' experiences using this technology in clinical practice. Our objective was to improve understanding about the use of smart pumps in clinical practice. Methods: Four focus groups of 60 to 90 minutes were held with practicing registered nurses in March and April 2005. Sessions were audiotaped, transcribed verbatim, and analyzed using deductive and inductive methods to answer our research question about smart pump usage and to identify emergent themes in the data. Results: Nurse participants had an average of 3½ years of experience using smart pumps in diverse clinical settings. Several mechanical issues related to pump use were noted, including difficulties with tubing, battery life, and pump weight. Challenges associated with smart pump usage such as inconsistencies in the smart pump drug library and IV medication preparation were also discussed. Nurses described different strategies to overcome smart pump use challenges including disabling the safety software features of the smart pumps, especially in cases where there were differences between drug volumes and concentrations, limitations on dosing units, or limitations on medication administration rates. Conclusions: Smart pumps offer the potential to improve IV medication administration safety in the medication administration process, but work-arounds can introduce the possibility of new errors. Organizations introducing smart pumps should investigate actual usage at the point of care, and consider opportunities to accommodate modifications to the decision support software, or implement use standards to facilitate appropriate smart pump use.

[1]  A. Strauss,et al.  The discovery of grounded theory: strategies for qualitative research aldine de gruyter , 1968 .

[2]  D. Morgan.  Focus groups for qualitative research. , 1988, Hospital guest relations report.

[3]  C. Aydin.  Occupational adaptation to computerized medical information systems. , 1989, Journal of health and social behavior.

[4]  T. Brennan,et al.  The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. , 1991, The New England journal of medicine.

[5]  Mark A. Constas,et al.  Qualitative Analysis as a Public Event: The Documentation of Category Development Procedures , 1992 .

[6]  M. Lorentzon.  Doing Qualitative Research , 1993 .

[7]  D. Bates,et al.  Systems analysis of adverse drug events. ADE Prevention Study Group. , 1995, JAMA.

[8]  M. Shields,et al.  Errors in administration of intravenous drugs , 1995, BMJ.

[9]  Jonathan M. Teich,et al.  Research Paper: Implementation of Physician Order Entry: User Satisfaction and Self-Reported usage Patterns , 1996, J. Am. Medical Informatics Assoc..

[10]  D. Bates,et al.  Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. , 1998, JAMA.

[11]  N. Hoffart.  Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory , 2000 .

[12]  D. Bates.  Using information technology to reduce rates of medication errors in hospitals , 2000, BMJ : British Medical Journal.

[13]  J. Paton,et al.  Medication errors in a paediatric teaching hospital in the UK: five years operational experience , 2000, Archives of disease in childhood.

[14]  D. Bates,et al.  Medication errors and adverse drug events in pediatric inpatients. , 2001, JAMA.

[15]  P. Maurette,et al.  [To err is human: building a safer health system]. , 2002, Annales francaises d'anesthesie et de reanimation.

[16]  Emily S. Patterson,et al.  Research Paper: Improving Patient Safety by Identifying Side Effects from Introducing Bar Coding in Medication Administration , 2002, J. Am. Medical Informatics Assoc..

[17]  Thomas H. Payne,et al.  A cross-site qualitative study of physician order entry. , 2003, Journal of the American Medical Informatics Association : JAMIA.

[18]  D. Bates,et al.  Improving safety with information technology. , 2003, The New England journal of medicine.

[19]  E. Rogers,et al.  Diffusion of innovations , 1964, Encyclopedia of Sport Management.

[20]  G. Kuperman,et al.  Computer Physician Order Entry: Benefits, Costs, and Issues , 2003, Annals of Internal Medicine.

[21]  Roger B. Davis,et al.  Physicians' decisions to override computerized drug alerts in primary care. , 2003, Archives of internal medicine.

[22]  Nick Barber,et al.  Ethnographic study of incidence and severity of intravenous drug errors , 2003, BMJ : British Medical Journal.

[23]  K. Taxis,et al.  Causes of intravenous medication errors: an ethnographic study , 2003, Quality & safety in health care.

[24]  E. Oren,et al.  Impact of emerging technologies on medication errors and adverse drug events. , 2003, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[25]  J. P. Kichak,et al.  Computerized physician order entry: helpful or harmful? , 2003, Journal of the American Medical Informatics Association : JAMIA.

[26]  Colleen M. Malashock,et al.  Effect of Smart Infusion Pumps on Medication Errors Related to Infusion Device Programming , 2004 .

[27]  Marc Berg,et al.  Viewpoint Paper: Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors , 2003, J. Am. Medical Informatics Assoc..

[28]  A. McAlearney,et al.  Doctors' experience with handheld computers in clinical practice: qualitative study , 2004, BMJ : British Medical Journal.

[29]  Melissa M. Honour,et al.  Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. , 2004, Health affairs.

[30]  M. Sullivan,et al.  Preventing medication errors with smart infusion technology. , 2004, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[31]  Tony Delamothe,et al.  Open access publishing takes off , 2004, BMJ : British Medical Journal.

[32]  J. Feinglass,et al.  The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. , 2004, Archives of internal medicine.

[33]  I. Sim,et al.  Physicians' use of electronic medical records: barriers and solutions. , 2004, Health affairs.

[34]  Susan Thurman,et al.  An Intravenous Medication Safety System: Preventing High-Risk Medication Errors at the Point of Care , 2004, The Journal of nursing administration.

[35]  K. Taxis,et al.  An observational study of intravenous medication errors in the United Kingdom and in Germany , 2003, Pharmacy World and Science.

[36]  Marianne Fields,et al.  Intravenous Medication Safety System Averts High‐risk Medication Errors and Provides Actionable Data , 2005, Nursing administration quarterly.

[37]  B Sabatier,et al.  Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France , 2005, Quality and Safety in Health Care.

[38]  Elisabeth Burdick,et al.  A controlled trial of smart infusion pumps to improve medication safety in critically ill patients1 , 2007, Critical care medicine.

[39]  Geraldine A Coyle,et al.  Evolution of BCMA within the Department of Veterans Affairs. , 2005, Nursing administration quarterly.

[40]  D. Rooney,et al.  Insights from the sharp end of intravenous medication errors: implications for infusion pump technology , 2005, Quality and Safety in Health Care.

[41]  A. Localio,et al.  Role of computerized physician order entry systems in facilitating medication errors. , 2005 .

[42]  R. Wears,et al.  Computer technology and clinical work: still waiting for Godot. , 2005, JAMA.

[43]  M. Mccaffery,et al.  Authorized and unauthorized use of PCA pumps: clarifying the use of patient-controlled analgesia, in light of recent alerts. , 2005, The American journal of nursing.

[44]  S. Goldhaber,et al.  Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors , 2005 .

[45]  Remy R Coeytaux,et al.  Effect of a computerized prescriber-order-entry system on reported medication errors. , 2005, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[46]  Ann Scheck McAlearney,et al.  Utilization of evidence-based computerized order sets in pediatrics , 2006, Int. J. Medical Informatics.

[47]  David W. Bates,et al.  Systems Analysis of Adverse Drug Events , 2008 .