Judul : Development of a standardized, citywide process for managing smart-pump drug libraries

Abstract : False alerts, also referred to as clinically insignificant alerts among ICPS members, occur when
an alert is triggered but there is no need for end user intervention.3,4 These alerts have likely resulted in
a dulling effect on end users and minimized the important safety role infusion pumps can play in the
prevention of medication errors.5 A growing body of evidence in healthcare points to the fact that alert
fatigue can contribute to errors rather than preventing potential errors about which the alerts may be
forewarning.6,7 Alerting too often or in too many situations may cause users to ignore potentially
significant safety situations. Other highly complex and error prone industries have established error
alerting structures to minimize the number of “false-positive” alerts related to errors.8 Further
validating this concern was the approval of National Patient Safety Goal 06.01.01 (“Improve the safety of
clinical alarm systems”) in June 2013, 6 months after the formation of our work group.9 Furthermore,
variability within and lack of scrutiny of smart-pump drug libraries can create conditions directly
contributing to clinically insignificant alerts, such as those due to dosing limits that are too tightly
calibrated or out-of-date data and alerts linked to innocuous events.

Disscusion : Lessons learned. Several key lessons were learned during the project. Even though pumps
may be updated more frequently, follow-up analysis of data should occur after a full quarter of data have
been collected in order to reassess effects of an implemented change. With several updates occurring
each year, educating all nurse and pharmacist end users across a practice site or health system can be
challenging. Incorporating key process champions at every step and using feedback from frontline staff
members can mitigate these challenges. Strong policies, procedures, and support from management
stakeholders can lead to increased accountability in an otherwise difficult change-control process.
Benefits of collaboration. Each of the case studies presented above highlights the benefit of multiple
health systems with established strengths collaborating to create an ideal smart-pump review process. By
having representatives of all ICPS member organizations articulate their experiences with key components
of the process, as outlined in the ICPS work group consensus statement, lessons learned can be applied
at all sites citywide. This standardized approach creates a culture of shared learning for everyone, resulting
in an accelerated rate of change across the community. This approach ultimately involves the end user in
the entire process and allows nurses and pharmacists to collaboratively manage smart pumps, resulting
in fewer clinically insignificant alerts.

Conclusion : Through implementation of a standardized, consensus-driven process for smart-pump drug

library optimization, ICPS member health systems reduced clinically insignificant smart-pump alerts.

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