Effect of Dose Error Reduction Software on the Ability of Nurses to Safely and Efficiently Administer

201 Pages·2009·1.85 MB·English

Effect of Dose Error Reduction Software on the Ability of
Nurses to Safely and Efficiently Administer Intravenous
Medications
by

Sarah Rothwell
A thesis submitted in conformity with the requirements
for the degree of Masters of Health Science in Clinical Biomedical Engineering
Institute of Biomaterials and Biomedical Engineering
University of Toronto
© Copyright by Sarah Rothwell 2009
The Effect of Dose Error Reduction Software on the Ability of
Nurses to Safely and Efficiently Administer Intravenous
Medications
Sarah Rothwell
Masters of Health Science in Clinical Biomedical Engineering
Institute of Biomaterials and Biomedical Engineering
University of Toronto
2009

Abstract
The purpose of this research was to compare the design of Dose Error Reduction Software (DERS)
between smart pumps to determine which features affect the ability of nurses to safely and efficiently
program intravenous medications. A high-fidelity usability experiment was conducted. Twenty-
four Registered Nurses completed a series of infusion tasks, in a simulated clinical environment,
using three smart pumps (Cardinal Alaris System, BBraun Infusomat, and Hospira Symbiq).
Results found significant differences in nursing performance across the smart pumps. Nurses
were more likely to override clinically inappropriate soft limit alerts when using BBraun
Infusomat, than when using Hospira Symbiq or Cardinal Alaris System. Furthermore, when
asked to program an infusion over a specific duration, nurses were found to make significantly
more parameter entry errors when using Hospira Symbiq than when using Cardinal Alaris
System. Results from this study will help set DERS design principles, and assist hospitals during
their procurement processes.

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Acknowledgements

First and foremost, I would like to thank my thesis supervisor, Dr. Tony Easty, for his guidance
and support during my time at the Centre for Global eHealth Innovation. His commitment to patient
safety is inspiring and truly infectious. I remain indebted to Dr. Patricia Trbovich for her assistance during
the development of this experiment, and analysis of the experimental results. I would also like to thank
my committee members, Dr. Joe Cafazzo, Dr. Diane Doran and Dr. Kim Vicente for their guidance.
Lastly, I would like to thank the Healthcare Human Factors Group for the use of their usability labs and
equipment, and their support over the last two years.
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Table of Contents
1. INTRODUCTION……………………………………………………………...………………………..1
1.2 Chapter Roadmap .............................................................................................................................. 2
2. BACKGROUND…………………………………………………………………………..…………….3
2.1 Medication Errors And IV Infusion Technology ................................................................................ 3
2.1.1 Medication Errors in the Medication Delivery System ............................................................ 3
2.1.3 IV Medication Errors .............................................................................................................. 4
2.1.4 Evolution of IV Infusion Safety and the Introduction of Smart Infusion Pumps ....................... 5
2.2 Challenges of Smart Infusion Pump Technology ................................................................................ 7
2.2.1 Poor Drug Library Compliance ............................................................................................... 7
2.2.2 User Errors ............................................................................................................................. 9
2.2.3 Override of Limit Alerts Judged Clinically Inappropriate ...................................................... 10
2.2.4 Problems Completing Complex Multi-Step Tasks ................................................................. 12
2.2.5 Multi-Channels ..................................................................................................................... 13
2.3 Improving IV Infusion Safety Using Human Factors Methods ......................................................... 14
2.3.1 Inquiry Methods ................................................................................................................... 14
2.3.2 Inspection Methods .............................................................................................................. 15
2.3.3 Testing Methods ................................................................................................................... 16
3. METHODLOGY………………………………………………………………………..…………...17
3.1 Materials ......................................................................................................................................... 17
3.1.1 Smart Pump Selection .......................................................................................................... 17
3.1.2 Drug Library Set-up ............................................................................................................. 18
3.1.3 Pump Configuration Settings ................................................................................................ 19
3.1.4 Medication Orders, labels and patient ID wristbands ............................................................. 20
3.2 Participants ...................................................................................................................................... 20
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3.3 Experiment Design .......................................................................................................................... 21
3.3.1 Independent Variables .......................................................................................................... 22
3.3.2 Dependent Variables ............................................................................................................ 24
3.3.3 Training Design .................................................................................................................... 25
3.3.4 Experiment Set-up Design .................................................................................................... 26
3.4 Experiment Protocol ........................................................................................................................ 27
3.4.1 Roles of Experiment Team ................................................................................................... 27
3.4.2 Protocol ................................................................................................................................ 28
3.5 Data Collection ................................................................................................................................ 29
3.6 Data Analysis .................................................................................................................................. 29
3.6.1 Error Detection ..................................................................................................................... 29
3.6.2 Efficiency ............................................................................................................................. 31
3.6.3 Success Rate ......................................................................................................................... 35
3.6.4 Deviations ............................................................................................................................ 36
3.6.5 Parameter Entry .................................................................................................................... 37
3.6.6 User Errors ........................................................................................................................... 38
3.6.7 Survey Results ...................................................................................................................... 38
4. RESULTS…………………………………………………………………..………………………..39
4.1 Continuous Infusion Task ................................................................................................................ 39
4.1.1 Efficiency ............................................................................................................................. 39
4.1.2 Success Rate ......................................................................................................................... 41
4.1.3 Deviations ............................................................................................................................ 41
4.2 Intermittent Infusion Task ................................................................................................................ 42
4.2.1 Efficiency ............................................................................................................................. 42
4.2.2 Success Rate ......................................................................................................................... 44
4.2.3 Parameter Entry .................................................................................................................... 45
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4.2.4 Deviations ............................................................................................................................ 46
4.3 Drug not in Drug Library Infusion Task ........................................................................................... 47
4.3.1 Efficiency ............................................................................................................................. 47
4.3.2 Success Rate ......................................................................................................................... 48
4.3.3 Parameter Entry .................................................................................................................... 49
4.3.4 Deviations ............................................................................................................................ 49
4.4 Maintenance Infusion Task .............................................................................................................. 51
4.4.1 Efficiency ............................................................................................................................. 51
4.4.2 Success Rate ......................................................................................................................... 52
4.4.3 Deviations ............................................................................................................................ 53
4.5 Secondary Infusion Task .................................................................................................................. 53
4.5.1 Efficiency ............................................................................................................................. 53
4.5.2 Success Rate ......................................................................................................................... 54
4.5.3 Parameter Entry .................................................................................................................... 56
4.5.4 Deviations ............................................................................................................................ 56
4.6 Limit Alert Messages ....................................................................................................................... 57
4.7 User Errors ...................................................................................................................................... 58
4.8 Wrong Drug Detection ..................................................................................................................... 60
4.9 Wrong Patient Detection .................................................................................................................. 60
4.10 Inter Rater Reliability .................................................................................................................... 61
5.0 DISCUSSION……………………………………………………………………………………….62
5.1 Infusion tasks: Overall performance ................................................................................................. 62
5.1.1 Task completion time ........................................................................................................... 62
5.1.2 Task success rate .................................................................................................................. 63
5.2 Subtask Usability ............................................................................................................................. 63
5.2.1 Loading the IV set ................................................................................................................ 64
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5.2.2 Enter DERS and CCA .......................................................................................................... 66
5.2.3 Select Drug Name and Concentration ................................................................................... 68
5.2.4 Enter Parameters .................................................................................................................. 71
5.3 Secondary Infusions ........................................................................................................................ 76
5.3.1 Secondary Infusion Design Overview ................................................................................... 76
5.3.2 Accessing the Secondary Feature .......................................................................................... 77
5.4 Drug Not in Drug Library ................................................................................................................ 78
5.4.1 Generic Programming Design Overview ............................................................................... 78
5.4.2 Accessing the Generic Programming Mode .......................................................................... 79
5.4.3 Entering Parameters.............................................................................................................. 80
5.5 Limit Alert Messages ....................................................................................................................... 81
5.6 Wrong Patient and Drug Errors ........................................................................................................ 83
5.7 User Errors ...................................................................................................................................... 83
5.7.1 Calculation Errors ................................................................................................................ 83
5.7.2 Parameter Selection Errors ................................................................................................... 84
5.7.3 Unit Errors ........................................................................................................................... 85
5.7.4 Transcription Errors.............................................................................................................. 85
5.8 Nursing Perceptions ......................................................................................................................... 86
5.9 Study Limitations ............................................................................................................................ 87
5.10 Validation of the Hypotheses ......................................................................................................... 88
5.11 Future Work .................................................................................................................................. 90
5.12 Relevance to the field .................................................................................................................... 91
6.0 CONCLUSION……………………………………………………..……………………………...93
7.0 REFERENCES…………………………………………...…………………..……….………………96
8.0 APPENDIX A: Methods……………………………….…………………………………………100
9.0 APPENDIX B: Experimental Protocol…………………………………………………………..112
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10.0 APPENDIX C: Workflow diagrams……………………………………………………………158
11.0 APPENDIX D: Results……………………………….…………………………………………185
11.1 Continuous Infusion ..................................................................................................................... 168
11.2 Intermittent Infusion .................................................................................................................... 170
11.3 Drug Not in Drug Library ............................................................................................................ 172
11.4 Maintenance Fluid ....................................................................................................................... 174
11.5 Secondary Infusion ...................................................................................................................... 176
11.6 Hard Limit Alerts......................................................................................................................... 179
11.7 Wrong Drug ................................................................................................................................ 179
11.8 Wrong Patient .............................................................................................................................. 180
11.9 Survey Results ............................................................................................................................. 180
11.10 Inter rater reliability ................................................................................................................... 183

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A List of Figures

Figure 1: Mean task completion time and standard deviation for Cardinal Alaris System, BBraun
Infusomat, and Hospira Symbiq when programming a continuous infusion (n =18) ................................ 40

Figure 2: Mean subtask completion time and standard deviation for Cardinal Alaris System, BBraun
Infusomat, and Hospira Symbiq when programming a continuous infusion (n = 18) ............................... 41

Figure 3: Mean task completion time and standard deviation for intermittent infusion task when
programming Cardinal Alaris System, BBraun Infusomat and Hospira Symbiq (n = 15) ........................ 43

Figure 4: Mean subtask completion time and standard deviation for intermittent infusion task when using
Cardinal Alaris, BBraun Infusomat, and Hospira Symbiq (n = 15) ......................................................... 44

Figure 5: Percentage of nurses that successfully completed each programming subtask in the intermittent
infusion task when using Cardinal Alaris System, BBraun Infusomat, and Hospira Symbiq (N = 24) ..... 45

Figure 6: Percentage of nurses that deviated in the intermittent infusion subtasks when using Cardinal
Alaris System, BBraun Infusomat and Hospira Symbiq (N=24) ............................................................. 46

Figure 7: Mean subtask completion time and standard deviation for Cardinal Alaris System, BBraun
Infusomat, and Hospira Symbiq when programming a generic infusion (n = 10) .................................... 48

Figure 8: Percentage of nurses that successfully completed each programming subtask of the drug not in
drug library infusion task when using Cardinal Alaris System, BBraun Infusomat, and Hospira Symbiq
(N=24) .................................................................................................................................................. 49

Figure 9: Percentage of nurses that deviated in each programming subtask for the drug not in drug library
infusion task when using Cardinal Alaris System, BBraun Infusomat and Hospira Symbq (N=24) ......... 50

Figure 10: Mean subtask completion time and standard deviation for maintenance infusion task when
using Cardinal Alaris, BBraun Infusomat, and Hospira Symbiq (n = 16) ................................................ 52
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Figure 11: Mean task completion time and standard deviation for secondary infusion task when using
Cardinal Alaris, BBraun Infusomat, and Hospira Symbiq (n = 16) ......................................................... 54

Figure 12: Percentage of nurses that successfully completed the secondary infusion subtasks when using
Cardinal Alaris System, BBraun Infusomat, and Hospira Symbiq (N=24) .............................................. 55

Figure 13: Percentage of nurses that deviated during the secondary infusion subtasks for Cardinal Alaris
System, BBraun Infusomat and Hospira Symbiq (N=24) ....................................................................... 57

Figure 14: Percentage of nurses that detected and successfully remediated dose error that would result in a
soft limit alert when using Cardinal Alaris System, BBraun Infusomat and Hospira Symbiq. (n=22) ...... 58

Figure 15: Percentage of infusions programmed that contained each type of user error when using
Cardinal Alaris System, BBraun Infusomat, and Hospira Symbiq (N = 168) .......................................... 59

Figure 16: Percentage of infusions programmed that contained user errors which resulted in task failure
when using Cardinal Alaris System, BBraun Infusomat and Hospira Symbiq (N = 168) ......................... 60

Figure 17: Illustration of a typical active field for Hospira Symbiq......................................................... 68

Figure 18: Illustration of Cardinal Alaris System's hierarchical drug list navigation method ................... 69

Figure 19: Example of drug list navigation method for BBraun Infusomat ............................................. 69

Figure 20: Parameter Entry Screens for Cardinal Alaris System. Left figure displays the parameter entry
screen for primary infusions, and the right figure display the parameter entry screen for continuous
infusions. ............................................................................................................................................... 71

Figure 21: Parameter Entry Screens for BBraun Infusomat. Left figure displays the parameters visible on
the main screen upon entry to this menu level. Right figure displays the second set of parameters that can
be accessed by scrolling down the parameter list .................................................................................... 72

Figure 22: Parameter Entry Screen for Hospira Symbiq ......................................................................... 72
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