A fundamental difference in how we practice medicine as anesthesiologists as compared to the rest of medicine involves drug administration. We “order” the drugs the patient needs, draw up (“dispense”) our own drugs, administer them to patients without any oversight, and personally document what we’ve administered in the anesthetic record. And we do this in a working environment that is distracting, and we rely on “on situational awareness, mental focus, and vigilance in order to reduce the chance of medication errors (MEs) occurring. However, human errors are an inevitable outcome of poor human reliability; so it is essential that steps are taken to minimize errors and harm”.1 Think about the chain of events that occur in how other specialties in your hospital do this: 1) a doctor or increasingly a nurse practitioner or physician’s assistant makes a diagnosis and enters an order for a drug on the EMR, 2) the order is transmitted to a pharmacy whereupon a pharmacist checks the dose and the drug, draws up the drug and labels it, sends it to the floor, 3) there a nurse checks the order against what was ordered and what was actually sent from the pharmacy to the floor; if the drug is a “high risk” medication or is being given via an infusion pump, the nurse finds another nurse to double check the drug and pump programming (“independent double verification”) , and 4) then documents in the EMR.
Our anesthesia process is core to how we practice, but does it meet the current safety standards? Indeed, others in the hospital, particularly those tasked with quality and safety, think that how we administer drugs is unsafe, antediluvian, and well nuts. In today’s PAAD we’ll take a fresh look at 2nd person verification of infusion pump programming. But first a recurrent thought from the late President Ronald Reagan:
Original article
Raghavan, Kavitha C. MBBS, FRCA*; Burlison, Jonathan D. PhD†; Sanders II, Edward M. MSN, CRNA*; Rossi, Michael G. DO, FAAP*. Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm. Pediatric Quality and Safety: September/October 2022 - Volume 7 - Issue 5 - p e596 doi: 10.1097/pq9.0000000000000596
“Programmable computerized drug infusion devices, also known as smart pumps, are used routinely to administer anesthetic agents and vasoactive medications during anesthesia. About 20 years ago, smart pumps with dose error reduction systems (DERSs) and drug libraries were introduced into healthcare to improve medication infusion safety. This has led to the standardization of infusion practices, drug concentrations, dose/dose-rate nomenclature, and dosing limits. Despite this, wrong-patient errors, wrong DERS library selections, errors due to incorrect programming, and errors due to alert overrides continue.”.2 Adverse drug events (ADEs) due to incorrect programming of propofol infusion pumps and other medication errors have been reported in children receiving anesthesia.3,4 Are these errors preventable? In 2004, Jensen et al.5 made the following recommendations: “systematic countermeasures should be used to decrease the number of drug administration errors in anaesthesia; the label on any drug ampoule or syringe should be read carefully before a drug is drawn up or injected; the legibility and contents of labels on ampoules and syringes should be optimised according to agreed standards; syringes should (almost) always be labelled; formal organisation of drug drawers and workspaces should be used; labels should be checked with a second person or a device before a drug is drawn up or administered.”
Raghavan et al. introduced, in a single center (St. Jude Children’s Research Hospital, Memphis TN), two-person independent verification of pump programming during anesthesia in order to reduce adverse drug events due to infusion pump errors to zero.2 And they succeeded! There was one adverse event during the study period but it was caused by a member of the anesthesia team who did not conform to the 2 person verification protocol. Thirteen near misses were averted. The verification process did not delay or increase operating or procedure suite room time. Finally, the authors discuss in great detail the systemic and cultural factors that affected the implementation of this process and how it affected the project’s outcome.
The key to this protocol is who provided the 2nd verification check? Since the majority of cases performed in this study had an attending physician and nurse practitioner, initially the second person was an anesthesia provider already assigned to the case. Over time this was expanded to any anesthesia provider that was available. “An electronic verification process via PatientTouch (Patient Safe Solutions) was introduced for single-provider anesthesia encounters. The provider programming the pump would send out 2 pictures, one with the patient’s EMR with his/her name, medical record number, and weight, and the other with the pump program to the anesthesiology clinical directors, CRNA manager, CRNA board runner, and the CRNA champion. The infusion would commence after the first provider received a verification check message from any of the above providers.”2
For many hospitals, the reported process may be an overly complex and near impossible solution for the 2nd verification check. In our view, it would be far simpler to have the circulating nurse (RN) in the OR or procedure center do this. Indeed, for drugs like propofol, it could be done during the time out. Nevertheless, this study demonstrates that 2-provider verification of infusion pump programming during anesthesia can be successfully implemented. Regardless of what you do for infusion pumps, we also think that 2nd verification steps are essential, really mandatory, when high-risk medications are administered in the OR like insulin, heparin, protamine, etc.
Finally, in Colorado, JT Thomas and his colleagues implemented the Codonics Safe Label System®, an automated labeling system (ALS), to increase compliance with labeling guidelines in the OR to help reduce medication errors.6 In Seattle, Grigg et al. developed a medication cart template to organize how drugs were laid out.7 What are you doing in your practices to minimize medication errors? Send us your thoughts and we’ll publish in a future reader response.
References
1. Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Educ 2019;19(5):151-157. (In eng). DOI: 10.1016/j.bjae.2019.01.001.
2. Raghavan KC, Burlison JD, Sanders II EM, Rossi MG. Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm. Pediatric Quality & Safety 2022;7(5):e596. DOI: 10.1097/pq9.0000000000000596.
3. Lobaugh LMY, Martin LD, Schleelein LE, Tyler DC, Litman RS. Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative. Anesthesia and analgesia 2017;125(3):936-942. (In eng). DOI: 10.1213/ane.0000000000002279.
4. Martin LD, Grigg EB, Verma S, Latham GJ, Rampersad SE, Martin LD. Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia. Paediatric anaesthesia 2017;27(6):571-580. (In eng). DOI: 10.1111/pan.13136.
5. Jensen LS, Merry AF, Webster CS, Weller J, Larsson L. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia 2004;59(5):493-504. (In eng). DOI: 10.1111/j.1365-2044.2004.03670.x.
6. Thomas JJ, Bashqoy F, Brinton JT, Guffey P, Yaster M. Integration of the Codonics Safe Label System(®) and the Omnicell XT(®) Anesthesia Workstation into Pediatric Anesthesia Practice: Utilizing Technology to Increase Medication Labeling Compliance and Decrease Medication Discrepancies While Maintaining User Acceptability. Hospital pharmacy 2022;57(1):11-16. (In eng). DOI:
7. Grigg EB, Martin LD, Ross FJ, et al. Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study. Anesthesia and analgesia 2017;124(5):1617-1625. (In eng). DOI: 10.1213/ane.0000000000001823.10.1177/0018578720970464.
Thank you for presenting a critical discussion in our anesthesia practice. My group is very invested in medication safety, and we perform mandatory 2-person infusion verification in every anesthetic. For solo providers, I suggest a few tools already available in the electronic anesthesia record and data collection. One is the displayed “calculated dose” for the child when the provider enters the medication and its intended “dose/weight” in the record; the other is the “calculate rate” when the provider enters the intentional “dose/weight/time” in the electronic record for infusions. The “calculated rate” should cross-check with the infusion rate being delivered to the patient. A provider may need to perform this step multiple times in a given anesthetic and with multiple infusions sometimes.
Another important habit is to save or retain all vials during the case. This step allows you to verify the medication source with colleagues, especially during hand-offs where the other provider would like to “trust but verify” what has been prepared in each syringe or delivered to the child.
Finally, we are implementing barcode medication administration (BCMA) where, instead of manually entering the documentation of drugs in the record, we scan the drug or prefilled syringe into the electronic record. This practice is as close as we can get to achieve the 5 “rights” of medication administration in anesthesia.