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Observational Study
. 2015 Dec 11:15:206.
doi: 10.1186/s12887-015-0521-6.

Smart pumps and random safety audits in a Neonatal Intensive Care Unit: a new challenge for patient safety

Elena Bergon-Sendin  1 , Carmen Perez-Grande  2 , David Lora-Pablos  3 , María Teresa Moral-Pumarega  4 , Ana Melgar-Bonis  5 , Carmen Peña-Peloche  6 , Mercedes Diezma-Rodino  7 , Lidia García-San Jose  8 , Esther Cabañes-Alonso  9 , Carmen Rosa Pallas-Alonso  10
Affiliations
Observational Study

Smart pumps and random safety audits in a Neonatal Intensive Care Unit: a new challenge for patient safety

Elena Bergon-Sendin et al. BMC Pediatr. .

Abstract

Background: Random safety audits (RSA) are a safety tool enabling prevention of adverse events, but they have not been widely used in hospitals. The aim of this study was to use RSAs to assess and compare the frequency of appropriate use of infusion pump safety systems in a Neonatal Intensive Care Unit (NICU) before and after quality improvement interventions and to analyse the intravenous medication programming data.

Methods: Prospective, observational study comparing the frequency of appropriate use of Alaris® CC smart pumps through RSAs over two periods, from 1 January to 31 December 2012 and from 1 November 2014 to 31 January 2015. Appropriate use was defined as all evaluated variables being correctly programmed into the same device. Between the two periods they were established interventions to improve the use of pumps. The information recorded at the pumps with the new security system, also extracted for one year.

Results: Fifty-two measurements were collected during the first period and 160 measurements during the second period. The frequency of appropriate use was 73.13 % (117/160) in the second period versus 0 % (0/52) in the first period (p < 0.0001). Information was recorded on 44,924 infusions; in 46.03 % (20,680/44,924) of cases the drug name was recorded. In 2.5 % (532/20,680) of cases there was an attempt to exceed the absolute limit.

Conclusions: Random Safety Audits were a very useful tool for detecting inappropriate use of pumps in the NICU. The improvement strategies were effective for improving appropriate use and programming of the intravenous medication infusion pumps in our NICU.

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Figures

Fig. 1
Fig. 1
The most commonly used drugs in our unit in 2014. Fentanyl 35.04 % (7,246/20,680), Gentamicin 12.58 % (2,601/20,680), Dopamine 10.73 % (2,218/20,680), Vancomycin 9.49 % (1,962/20,680), and Midazolam 8.80 % (1,819/20,680)
Fig. 2
Fig. 2
Distribution by month of alarms detected in medication programming in 2014
Fig. 3
Fig. 3
Distribution by time of day of alarms detected in medication programming in 2014
See this image and copyright information in PMC

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