BC Cancer Agency

Dose Error Reduction Software: Choosing the Least Risky IV PumpSue Fuller Blamey & Karen Janes

Objectives

To review two dose error reduction  software (DERS) IV pump to identify failure 

modes and mitigation strategies

To choose the least risky intravenous pump  that includes the most effective mitigation 

strategies to prevent IV errors

IV Pump Implementation Team

Team –

Nurses, senior leaders, Quality  Director, pharmacists, physicians

Human factors analysis

Conducted Failure Modes Effects Analysis to  identify failures, mitigation strategies and 

educational plans

Staff IV Pump testing

Process Flow/Failure Modes:   Alaris

and Hospira

Pumps

Root Cause Analysis

Root Causes of Failures

DERS Opt in software – staff have to go through multiple steps to opt in

Enter wrong BSA calculation

Culture of staff overriding safety steps

Lack of education

More than one type of pump in use

Forgot to unclamp IV set

FMEA Worksheet Analysis

Seve

rity

Prob

abili

ty

Haz

Sco

re

Sing

le P

oint

W

eakn

ess?

Exis

ting

Con

trol

M

easu

re ?

Det

ecta

bilit

y

Proc

eed?

1 User does not know correct method

Mod

erat

e

unco

mm

on

4 Y Y N Y C

More formal IV pump education

List of stattendingeducatio

HFMEA Subprocess Step Title and Number

Scoring Decision Tree AnalysisHFMEA Step 5 - Identify Actions HFMEA Step 4 - Hazard Analysis

Failure Mode: First Evaluate failure

mode before determining

potential causes

Potential CausesAction Type

(Control, Accept,

Eliminate)

1.1 Incorrect techniques

Actions or Rationale for Stopping

OutcoMeas

Comparing Risk

Risk Alaris Hospira

1. DERS Software Entry/Exit

Higher risk of non- compliance

Opt-out can occur but is not the path of least resistance

2. New Patient Selection

Risk of BSA user- based errors

Low risk with tight DERS limits

3. Loading of IV tubing

Potential for slowed incorrect rate

No risk

Comparing Risk

Risk Alaris Hospira

4. BSA Calculator

No risk – no BSA calculator

Potential for risk of user-based BSA errors

5. Syringe Pump Accuracy

+/- 2% +/- 5% (no paediatrics for BCCA)

6. Server 1 connectivity licence per pump is required to connect to external server

Server sits within PHSA domain

Comparing Risk

Risk Alaris Hospira

7. Wireless Issues with PHSA security network

Server sits within the PHSA network domain

8. Clinical simulation with nurses

More difficult to operate

Easier to prime tubing, more user friendly and intuitive

9. Ergonomic Difficult to open and closeManual loading

Push button/touch screen operatedAutomatic loading

Comparing Risk

Risk Alaris Hospira

10. Risk of repetitive strain injury (RSI)

Standard release system – at risk for RSI

Release system potentially reduces RSI

Overall risk Higher risk Lower risk

Decision‐making criteria – Hierarchy  of Effectiveness in preventing errors

Hierarchy of Effectiveness  of Interventions

1. Forced functions and constraints2. Automation/computerization3. Simplification/standardization4. Reminders, checklist, double-checks5. Rules and policies6. Education and information

Decision‐making Criteria

Forced functions of DERS Opt out technology forces staff to use DERS unless they go through multiple steps

Implemented a function where nurses have to formally request the Opt out in order to not use DERS

Results:  97.7% compliance with DERS  software from implementation date

Questions