Authors (including presenting author) :
Kwan WY(1), Li CML(1), Lo YC(1), Cheung OK(1), Chan YH(1), Ng LMM(1), Chow WYN(1), Kwok WM(1).
Affiliation :
(1) Nursing Services Division, Tseung Kwan O Hospital.
Introduction :
Infusion pumps are critical devices in healthcare, incidents associated with human error have raised significant safety concerns. To mitigate these risks, Nursing Services Division (NSD) implemented a Dose Error Reduction System (DERS) using a drug library as a risk reduction strategy. This initiative was driven by a sequence of incidents involving high-risk medications across multiple hospitals, emphasizing the urgent need for standardized methods in infusion medication administration.
Objectives :
1. To minimize human errors that lead to inaccurate infusion rates and dose calculation mistakes. 2. To standardize practices for medication administration across all clinical areas.
Methodology :
Incidents related to infusion pumps since 2018 were analysed, two dangerous drugs (Morphine and Midazolam) were identified as frequent contributors to infusion pump-related incidents. A thorough review of existing infusion drug administration practices, along with consultations with the pharmacy and clinical team, led to the establishment of standard dilutions and hard limits for each drug. The models and stock of syringe pumps available in the general wards were also reviewed, and one commonly used syringe pump model was selected for installation. NSD nursing staff provided infusion pump safety education and proceeded to install the drug library across all clinical areas except ICU, CCU and Operating Theatre. One-month trial period was conducted before full implementation. Staff evaluation and usage stocktake were performed after the pilot period and full implementation.
Result & Outcome :
1. Total 100 infusion pumps have been equipped with the drug library in clinical areas, which included 85 in in-patient wards, 11 in day areas and 4 in out-patient areas.
2. The utilization rate was 84%, with 37% of cases using Morphine infusion alone, 38% using Midazolam infusion, and 25% using both Midazolam and Morphine infusion.
3. Feedback from nursing staff has been positive, with the majority reporting that the standardized settings have made the infusion pumps easier to use, and also reducing cognitive load and the likelihood of errors.
4. The absence of reported incidents related to infusion pump errors since the implementation indicates a reduction in administration errors.
5. Education on the safe use of the drug library has been incorporated into the regular training program for new nurses.
6. Corporate Standard Dilution Table will be incorporated to drug library to ensure uniformity and facilitate training.
