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How Using Data Analytics Can Change Provider Behavior

News  |  By PSQH  
   June 15, 2017

A data-driven initiative raises nurse engagement in smart pump safety improvement  and helps create a continuous quality loop to strengthen patient safety and gain data-driven insights.

This article first appeared June 12, 2017 on PSQH: Public Safety & Quality Healthcare.

By Nicole Karchner, PharmD

The introduction of “smart pumps” 15 years ago began a new era in IV medication safety. Many of the medications infused directly into a patient’s bloodstream (sedatives, insulin, anticoagulants, opioids) pose a high risk of patient harm; in fact, IV medication errors are twice as likely to cause patient harm compared to medications delivered via other routes (American Society of Health-System Pharmacists, 2008). A simple mistake in programming a pump—pressing “603” instead of “6.3,” or “25,000” instead of “2,500”—can deliver a massive, even fatal, overdose. With smart pumps, if infusion programming exceeds hospital-established limits, the dose-error-reduction software (DERS) generates an alert that must be addressed before infusion can begin. By using the safety features on smart infusion pumps, nurses can help improve patient safety and avert the medication errors associated with the greatest risk of harm: IV administration errors at the point of care (Wilson & Sullivan, 2004; Williams & Maddox, 2005; Fields & Peterman, 2005; Maddox, Danello, Williams, & Fields, 2008).

In addition to providing DERS, smart pumps also automatically capture previously unavailable data on IV infusions. An advanced data-analytics applicationa allows staff to more readily view, report, and use these data to identify key areas for improvement, without the burden and expense of additional staff, software, or daily data management. Staff can take actionable items such as necessary revisions to the DERS drug library, use their expertise to make the needed changes, and then implement the revised dataset hospitalwide in a continuous quality feedback loop.

Orange Regional Medical Center (ORMC) in Middletown, New York, is a 383-bed, Joint Commission–accredited hospital and member of the Greater Hudson Valley Health System (GHVHS). ORMC implemented smart pumpsa in 2005, followed by computerized prescriber order entry (CPOE) and barcode medication administration (BCMA) in 2011; it began regular use of the smart pump data-analytics applicationb in 2015.

Except for rare instances such as clinical emergencies or investigational drugs, nurses at ORMC are expected to use DERS for every IV infusion. Studies have revealed less valid reasons for not using DERS: underappreciation of risk, a failure to adjust the drug library when alerts are not credible, and a culture that tolerates at-risk workarounds (Institute for Safe Medication Practices, 2007).

Like many hospitals, ORMC found eliminating workarounds to be challenging. Despite extensive efforts, nurses continued to use the DERS drug-dosing safeguards for only 70%–75% of infusions. Then, in 2015, ORMC launched an innovative, data-driven IV Medication Safety Improvement Initiative that increased nursing compliance with the use of the DERS drug library for selection of the medication to be infused (Figure 1). Improved communications and advanced data analytics were keys to success.

This article includes a brief description of the IV Medication Safety Improvement initiative, the remotely hosted data-analytics application, and lessons learned for increasing pharmacy-nursing collaboration, optimizing the drug library, and improving smart pump drug-selection compliance and IV medication safety. 

IV medication safety improvement initiative

The overall goal of the initiative was to increase nurses’ compliance with selection of the medication to be infused from the DERS drug library. The question was, how could ORMC bring about the desired change in behavior? The Hierarchy of Controls advocated by the National Institute of Occupational Safety and Health (Figure 2) considers “administrative controls” (training and education) to be a less effective means to avoid exposing employees—or, in this case, patients—to potential harm.

With IV infusions, the best example of higher-level “engineering controls” is to integrate the smart pump system with the electronic health record (EHR). Interoperability automatically engages DERS for every infusion and pre-populates the pump with the ordered infusion parameters from the EHR. However, for many hospitals, interoperability is not a present reality. Another way to nurture compliance with smart pump technology and attention to the alerts is to optimize the smart pump drug library (Institute for Safe Medication Practices [ISMP], 2007). This increases the credibility of alerts, eliminates discrepancies between the drug libraries and actual practice, and makes it easier for nurses to select the medication from the drug library for every infusion.

Issues

To achieve this goal at ORMC, the following issues needed to be addressed:

Nurses were unaware of the lack of safeguards when the drug was not selected from the drug library and thus underappreciated the risk.

Nurses could not easily inform pharmacy about discrepancies between the smart pump drug libraries and actual practice.

Due to the lack of reporting from nursing, pharmacy was unaware of discrepancies that interfered with nurses’ use of the DERS drug library.

Without effective pharmacy-nursing collaboration to help optimize the drug library, it was not always easy for nurses to “do the right thing.” As a result, nurses did not always use the drug library to select the medications to be infused.

To address these issues and achieve the goal of increasing nurses’ selection of medications from the drug libraries, ORMC employed the methods shown in Table 1.

Education

The nursing educators invited clinical pharmacy leadership to speak to all nurses at the 2015 Nursing Annual Education sessions about the importance of using DERS. This was also emphasized in training for newly hired nurses and in face-to-face discussions with nurses at the bedside.

Easier reporting

A “drug hotline” and designated email address made it easy for nurses to submit valuable feedback. Such feedback helped identify changes that pharmacy needed to make to the smart pump drug library. Regular IV Safety Improvement bulletins encouraged nurses to inform pharmacy of any needed improvements to the DERS drug library—for example, if a drug limit was not in alignment with actual practice and thus frequently overridden, or if a commonly used drug concentration was not in the drug library. Whenever a discrepancy report was received, a response was sent by return email, informing the nurse that the change would be made and when it would happen, or that further research/consideration would be needed. Rapid feedback was critical to the success of this initiative.

Change requests were submitted to the clinical pharmacy team for review. After review, revisions were made to the drug library, which was then double-checked by two pharmacists before being “pushed out” wirelessly to the pumps. A tip sheet notified clinicians of the changes. Seeing drug library improvements resulting from their efforts further motivated nurses to report discrepancies and, most importantly, to select the medication from the DERS drug library for all IV medication infusions.

Use data to help change behavior

The remotely hosted, advanced data-analytics application played a critical role in the IV Medication Safety Improvement Initiative (Box 1). The application reported DERS usage for each infusion, which made compliance with selecting the medication from the drug library easier to see and allowed the nursing staff to more easily monitor their performance. Authorized staff could access the smart pump data anywhere, anytime from an appropriate digital device. Retrospective data aggregated from the hospital’s smart pump system could be easily viewed on the application’s “dashboard” display.

Staff could easily review, report, create graphs and slides, and share important information with nursing directors, educators, senior management, and—most importantly—bedside clinicians.

Reporting DERS usage rates by unit was challenging, because the pumps were mobile and moved regularly around the hospital. However, rates could be tracked by patient profile. Medical/surgical nurses, for example, could easily see how they compared to critical care nurses. Having the nurses see the data on a regular basis also sparked a spirit of competition between departments, which further increased motivation and nursing engagement in the initiative.

Provide frequent, fresh communication

Report distribution started out weekly, then changed first to biweekly and later to monthly as nurses’ use of the DERS drug library began to increase (Table 1). At first, IV Safety Improvement bulletins were distributed to the chief nursing officer, nursing directors, and nursing educators, but not to individual nurses (who were already receiving a great deal of email). As awareness increased and nurses became more interested and involved, individuals were added to the email distribution list.

Continuously updating the before-and-after data kept the information fresh, kept nurses interested, showed their successes, and fostered a spirit of competition. As nurses saw improvements reflected in the changing data, they became increasingly involved in pharmacy-nursing collaboration (Box 2).

Results

IV medication safety improvements

Using data to help drive improvement resulted in steady increases in the use of the DERS drug library to select the medication to be infused (Figures 1, 3, and 4).

Other results

The IV Medication Safety Improvement Initiative also:

  • Provided nursing and physician education regarding the importance of using DERS
  • Provided a mechanism for nursing to inform pharmacy of any discrepancies between the drug library and actual practice
  • Eliminated reported discrepancies between the drug library and actual practice
  • Increased pharmacy-nursing collaboration
  • Identified drug library entries that needed to be added or updated
  • Increased nursing engagement
  • Increased use of DERS safeguards by selecting the medication to be infused from the drug library
  • Helped strengthen ORMC’s culture of safety

Recognition

Every year, ORMC departments can submit one or more projects for an enterprisewide quality and patient safety award. In 2015, the IV Safety Improvement initiative was awarded top honors at the GHVHS Quality and Patient Safety Awards, an important validation of the staff’s concerted, innovative efforts and results.

Next steps

Considerable progress has been made in putting DERS and continuous quality improvement at the forefront of medication safety awareness. Nonetheless, there is more work to be done. Pharmacy presentations at nursing education sessions and monthly reports on DERS usage continue. Multiple communication channels are still available. Email has emerged as the most commonly used means of communication.

In the future, staff will also analyze data on “good catches,” alerts, and overrides as another way to identify needed improvement in nursing practice and/or smart pump drug libraries. The smart pump data and remotely hosted data-analytics application can also be used to help staff demonstrate cost avoidance, return on investment achieved through a reduction in adverse drug events, and the hospital’s compliance with certain requirements of The Joint Commission. Finally, optimizing the drug libraries helps pave the way for future implementations of smart pump-EMR interoperability.

Lessons learned

Eliminating mismatches in the smart pump drug library helps drive use of DERS

Education, easy-to-use reporting systems, face-to-face discussions, and ongoing communication with frontline nursing are effective ways to educate the nursing staff and discover inadequacies in the drug library

Responding to nursing feedback in a timely manner keeps staff engaged

Frequent communication of data showing progress is essential

Data reports help celebrate nurse accomplishments and further strengthen nursing engagement in the IV medication safety improvement efforts

Conclusion

The ISMP points out that, like seat belts, the safety features of any safety technology can be bypassed, despite various mandates requiring their use. “Thus, it is not enough to purchase smart pumps, program the library to enable the technology, distribute the pumps, educate users, and hope that the dose-checking feature will always be used. A culture of safety must exist that drives clinicians to avoid bypassing such a safety feature, or to report conditions that encourage workarounds so they can be remedied” (ISMP, 2007).

At ORMC, before-and-after data from the analytics reports provided “something new” that helped to increase staff awareness of the need to always select the medication to be infused from the DERS drug library, motivate staff to report conditions that could encourage workarounds, and increases nurses’ engagement in the medication safety improvement process. Nurses continue to work with pharmacy to keep the drug library up to date. They know that their feedback is important and have become increasingly engaged in the compliance-improvement process. They recognize more fully that smart pump safety features can save lives and have to be used. Continuously fine-tuning the drug library in the continuing quality loop helps ensure that bedside clinicians have the latest data set for the safest clinical practice—and that the right thing to do is the easy thing to do.


Note: We would like to express our appreciation to BD and Sally Graver for helping to ensure accuracy and completeness during manuscript development.

Footnotes:

  1. a. Alaris System, with Guardrails Suite MX software, BD. Franklin Lakes, NJ.
  2. b. Knowledge Portal for Infuse on Technologies, BD. Franklin Lakes, NJ.

Nicole Karchner, PharmD, was the clinical pharmacy manager at Orange Regional Medical Center in Middletown, New York from 2009 to 2016. She is now the director of pharmacy management for Crystal Run Health Plans. She can be contacted at ekarchner@crystalrunhp.com.


REFERENCES

The National Institute for Occupational Safety and Health (NIOSH). (2016, July 16). Hierarchy of Controls. Retrieved March 2, 2017 from https://www.cdc.gov/niosh/topics/hierarchy/default.html.

  1. American Society of Health-System Pharmacists. (2008). Proceedings of a summit on preventing patient harm and death from IV medication errors. Am J Health-Syst Pharm, 65(24), 2367–2379.
  2. Fields, M., & Peterman, J. (2005). Intravenous medication safety system averts high-risk medication errors and provides actionable data. Nurs Admin Quar, 29(1), 78–87.
  3. Institute for Safe Medication Practices. (2007, April 19). Smart pumps are not smart on their own. ISMP Medication Safety Alert! Retrieved March 2, 2017 from http://www.ismp.org/newsletters/acutecare/articles/20070419.asp.
  4. Maddox, R., Danello, S., Williams, G. K., & Fields, M. (2008). Intravenous infusion safety initiative: Collaboration, evidence-based best practices, and “smart” technology help avert high-risk adverse drug events and improve patient outcomes. In K. Henriksen, J. B. Battles, M. A. Keyes, & M. L. Grady (Eds.), Advances in Patient Safety: New Directions and Alternative Approaches, Vol. 4 (pp. 143–156). Rockville, MD: Agency for Healthcare Research and Quality.
  5. Orange Regional Medical Center (ORMC). (2015). IV Medication Safety Improvement Initiative, data on file.
  6. Williams, C. K., & Maddox, R.R. (2005). Implementation of an I.V. medication safety system. Am J Health-Syst Pharm, 62(5), 530–536.
  7. Wilson, K., & Sullivan, M. (2004). Preventing medication errors with smart infusion technology. Am J Health-Syst Pharm, 61(2), 177–183.

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