Transcript Graseby Pump Monitoring and Management Software

Medication Error Reduction
(MER)
with
Graseby Pumps
Raph Samuel
13 November, 2003
Medication Error Statistics
• Represent the largest single cause of errors in
hospitals
• Eighth leading cause of death
• Accounts for more than 7000 deaths annually in USA
alone
• Estimated cost per incident £1600 + 5 day in hospital
Figures from Institute of medicine (IOM)
Common Types of Medication Errors
Common Types
of Errors
Prescribing
Distribution
of Errors
Percentage
intercepted
39%
48%
CPOE
Solutions
12%
33%
CPOE
Solutions
11%
34%
Dispensing
Software
38%
2%
Graseby MER
Solutions
Wrong Dose, Wrong Drug or
Allergy
Transcribing
Wrong Dose, Wrong Frequency
or Missed Dose
Dispensing
Wrong Dose, Wrong Drug,
Wrong Time
Administering
Wrong Dose, Wrong Drug
Smiths Business Statement
• Smiths Medical is committed and
actively promoting a program to reduce
the number and severity of medication
errors through the use of Graseby
infusion devices. We have added new
software features to our existing
product line that will help reduce the
possibility of incorrectly programming
an infusion device at the bedside.
Some areas to address
• Excess manual operations on complex
equipment
– Drug Protocols, Good pump interface etc.
• Staff competence assessment and training
– Programming error log for analysis
• Availability of information
– Medical devices connectivity, Patient allergies etc.
• Labelling of medication
– Drugs look and sound similar
• Patient identification
– Right patient right medication
Graseby MER Solutions
Excess manual operation
• Graseby Pump Drug Protocols:
– Define the pump infusion program and
Parameters: Infusion mode, Rate, KVO etc.
– Prepared by ‘clinical experts’
– Used by ‘non experts’
– Reduces or even eliminates manual
keystrokes to correctly start an infusion at
POC
– Hard and Soft Parameter Limits
Graseby MER Solutions
Staff Assessment and Training
• Develop better system for monitoring
and reporting adverse events (Reactive
measures):
– Programming error log with nurse and patient
identity
– Remote monitoring of multiple pumps
– Remote alarms and events alerts
– Event history log on pump
– Real time remote history download
Graseby MER Solutions
Availability of Information
• Increase use of Information Technology :
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High speed pump networking - TCP/IP
Wireless – 802.11 option
XML/HL7 communication protocol
Encryption
Use conventional computer & PDA
Interface to industry standard PDMS
Use Graseby proprietary PC Software for best data
and protocol remote management
Graseby MER Solutions
Labelling of Medication
• Use of machine-readable coding:
– Use barcode on
• Drug
– Identifies and displays drug
– Could be used to set up infusion parameters
• Patient
• Infusion Device
• Clinician
Graseby MER Solutions
• Proactive measures to cross-check
that easily fits with existing
systems:
– Right
– Right
– Right
– Right
Drug
Patient
Pump Settings
time of medication delivery
Graseby MER Solutions
Modular approach
• Stand alone System:
Graseby Pump
Protocol Software
Network Comms.
TCP/IP
XML/HL7
Encryption
Barcode
Reader
Graseby MER Solutions
Modular Approach Cont.
• Locally Connected System:
Graseby Pump
Protocol Software
Network Comms.
Barcode
Reader
XML/HL7
Graseby Pump
Monitoring and
Management
Software
Encryption
MEDSHIELD
TCP/IP
Input
Device
Display
Graseby MER Solutions
Modular Approach Cont.
• Hospital Networked System:
Graseby Pump
Protocol Software
Network Comms.
Barcode
Reader
XML/HL7
Patient Data
Management
Software
Encryption
e.g. Siemens
TCP/IP
Graseby MER Future Progress
What do we need to do now:
– Establish close co-operation with societies such
as SCATA
– Define a Master Drug Library (MDL)
– Establish a working arrangements with hospitals to
try out different ideas in
• Initially, non clinical environment
• Eventually in clinical application