Who is responsible for the safety of infusion devices? It's high time for action!

M edication errors are unacceptably common. They occur during each step in the process of providing medication to hospital inpatients; prescribing, preparation, and administration. A recent UK study found a prescribing error in 1.5% of all medication orders written (a potentially serious prescribing error in 0.4%). Even higher error rates are associated with the administration of medication, in particular with intravenous medication. One or more errors occurred in about half of all intravenous drug preparations and administrations and 1% of doses were associated with a potentially severe outcome. Whereas the study by Taxis et al investigated a cross section of intravenous drug administrations including a large number of doses given by injection, the study by Husch et al focused on intravenous drugs administered via infusion pumps. Their study of 286 patients receiving infusion therapy found that almost 70% of intravenous doses were associated with an error, including three (out of 389) errors potentially causing temporary harm or prolonging hospitalisation. These studies indicate the urgent need to identify measures to reduce medication errors. Many strategies and technological advances have been discussed previously to reduce medication errors, including computerised physician order entry, participation of pharmacists on ward rounds, and bar coding of medication. The use of so-called ‘‘smart’’ infusion pumps is widely recommended to reduce intravenous medication administration errors. Smart pumps are infusion systems that allow entering drug infusion protocols into a library that can be used to specify pre-defined dose limits (with pumps alarming once these dose limits have been exceeded). Some measures, such as computerised physician order entry systems, have been shown to reduce medication errors in formal studies. However, little is known about the effects of smart pumps and thus the study by Husch and colleagues is timely. In contrast to common assumptions, they estimate that only one out of 389 errors related to the use of intravenous infusion devices may have been prevented by smart pumps. This was largely because the pumps currently available are insufficiently integrated into the system. For example, they are not linked to the electronic prescribing system or bar coded administration. The study clearly demonstrates that infusion devices need to be further developed to increase patient safety. The authors give a detailed outline of safety issues that need to be considered. Nonetheless, the potential of these infusion devices to reduce medication error must be ultimately tested in prospective studies. Given that such ideal infusion devices have been developed, are we likely to see the reduction in medication errors when they are routinely used in practice? A recent report by the UK National Patient Safety Agency (NPSA) indicates that the situation may be far more complex than expected. The NPSA performed a pilot study in six hospitals and found that an unnecessary wide range of different types of infusion pumps were used within the hospitals. Furthermore, the software of devices of the same type had multiple configurations and therefore reacted differently under the same circumstances. In addition the report highlighted that there was insufficient and inadequate staff training in the use of devices. It remains unknown how generalisable these data are to healthcare systems in other countries; however, it is likely that the isolated introduction of yet another new infusion device will fail to improve patient safety unless there is a well-coordinated approach. This includes monitoring the practical use of the infusion devices to identify potential safety issues. Providing intravenous drug therapy is a complex healthcare technology and different health professionals are involved in the process, including physicians, nurses, pharmacists, and medical engineers. Patients themselves and in some cases their carers also have an important role, in particular in patient controlled analgesic drug administration. Increasingly, pharmacists are seen (and want to be seen) as being responsible for medication safety issues in hospitals. For example, pharmacists perform regular prescription reviews in the UK, US, and Australian hospitals. Are they going to take the lead in this area? We have sufficient evidence about errors occurring with intravenous drug therapy and solutions are in sight. To achieve this goal, we need someone to take the responsibility for the safe and effective use of drug administration technologies. It’s high time for action!