University of Wisconsin–Madison

Smart IV Pump Implementation

  • Overview: Technology has been used to decrease medication errors; however, implementation of technology using human factors techniques is not routinely applied. Instead, failures in implementation and errors have occurred. The medication administration process has few double checks and new technology is available to decrease errors. Intravenous medication errors are among the most serious medication errors. Smart IV pumps have predefined medication dose limits. Their integration with bar code technology may be the ultimate defense for infusion errors.

    This study evaluates the implementation of Smart IV Pumps. The technology has the ability to decrease medication administration errors and change nurses’ and other users’ worklife. For that reason, a human factors approach of prospective error analysis is used to evaluate the technology and technology change process. Utilizing Failure Mode and Effects Analysis (FMEA), and results of work system and technology change surveys, one can improve implementation processes. Direct observations, surveys, and longitudinal assessment of the Smart IV Pump log data and error reports provide rich data on IV pump programming errors. Provider job and worklife characteristics affected by the change process can also be addressed. This study provides hospitals without medication administration technology, opportunities to assess and address human, medication, and organizational factors related to pump programming errors. Valuable information is gained about the technology change process associated with Smart IV Pump implementation to allow other hospitals to safely and effectively implement this technology and avoid new errors.

    The research is a collaborative project involving various departments and units at the University of Wisconsin-Madison (CQPI, Department of Medicine, Department of Anesthesiology, and School of Nursing) and the University of Wisconsin Hospital.

    Aims: The goals of this research project are:

    • to determine the effect of Smart IV Pump technology implementation and integration with bar code technology, supported by sophisticated human factors techniques, on medication errors;
    • to determine the impact of Smart IV Pump technology and the integration with bar code technology on nurses, pharmacists and physicians (end users); and
    • to describe a human factors error analysis and to qualitatively evaluate its effectiveness on the implementation success of technology in an acute care hospital setting.

    Funding: Agency for Healthcare Research and Quality (AHRQ)

  • Pascale Carayon, PhD
    Procter & Gamble Bascom Professor in Total Quality
    Department of Industrial and Systems Engineering
    Director, Center for Quality and Productivity Improvement
    University of Wisconsin-Madison

    Roger Brown, PhD
    Professor, University of Wisconsin-Madison School of Nursing
    Director, Research Design and Statistics Unit

    Ann Schoofs Hundt, PhD
    Research Scientist, Associate Director of Education
    Center for Quality and Productivity Improvement
    University of Wisconsin-Madison

    Steve Rough, RPh, MS
    Clinical Associate Professor of Pharmacy
    Director of Pharmacy, UWHC

    Mark Schroeder, MD
    Associate Professor of Anesthesiology
    School of Medicine and Public Health
    University of Wisconsin-Madison

    Tosha Wetterneck, MD, MS
    Associate Professor of Medicine
    School of Medicine and Public Health
    University of Wisconsin-Madison

    Mark Linzer, MD
    Professor-Medicine, University of Wisconsin-Madison
    Division of General Internal Medicine at Hennepin County Medical Center, Minnesota

    Myra Enloe
    Director
    Medical, Surgical and Oncology Nursing
    University of Wisconsin Hospital and Clinics

    Susan Kleppin
    Deputy Director
    Center for Drug Policy
    University of Wisconsin Hospital and Clinics

    Stephanie Kraus
    Associate Clinical Nurse Specialist
    University of Wisconsin Hospital and Clinics

    Brad C. Ludwig
    Assistant Director of Pharmacy
    Pharmacy Operations/Technology
    University of Wisconsin Hospital and Clinics

    Mustafa Ozkaynak, PhD
    graduate student in Industrial and Systems Engineering
    University of Wisconsin Madison

    Other people who worked on the project:

    Joshua De Silvey
    Inpatient Pharmacy Supervisor
    University of Washington Medical Center

    Tracy Love
    Former IV Pump Coordinator
    University of Wisconsin Hospital and Clinics

    Prashant Ram, MS, MBA
    graduate student in Industrial and Systems Engineering

    Tanita Roberts, PhD
    graduate student in Industrial and Systems Engineering

  • Carayon, P., Hundt, A.S., & Wetterneck, T.B. (2010). Nurses’ acceptance of smart IV pump technology. International Journal of Medical Informatics, 79 (6), 401-411. PMCID: PMC2862878

    Wetterneck, T.B., Hundt, A.S., & Carayon, P. (2009). FMEA team performance in health care: A qualitative analysis of team member perceptions. Journal of Patient Safety, 5 (2), 102-108. PMID: 19920449

    Koppel, R., Wetterneck, T., Telles, J.L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association,15 (4), 408-423. PMCID: PMC2442264

    Carayon, P., Wetterneck, T.B., Hundt, A.S., Rough, S., & Schroeder, M. (2008). Continuous technology implementation in health care: The case of advanced IV infusion pump technology. In Zink & Klaus (Eds.). Corporate Sustainability as a Challenge for Comprehensive Management. (pp. 139-151). Springer Press: Dordecht, The Netherlands.

    Carayon, P., Wetterneck, T.B., Hundt, A.S., Ozkaynak, M., DeSilvey, J., Ludwig, B., Ram, P., & Rough, S.S. (2007). Evaluation of nurse interaction with Bar Code Medication Administration (BCMA) technology in the work environment. Journal of Patient Safety, 3 (1), 34-42.

    Wetterneck, T.B., Skibinski, K., Roberts, T.L., Kleppin, S.M., Schroeder, M.E., Enloe, M., Rough, S.S., Hundt, A.S., & Carayon, P. (2006). Using failure mode and effects analysis to plan implementation of smart IV pump technology.American Journal of Health-System Pharmacy, 63 (16), 1528-1538. PMID: 16896081

    Schroeder, M.E., Wolman, R.L., Wetterneck, T.B., & Carayon, P. (2006). Tubing misload allows free flow even with smart intravenous infusion pump. Anesthesiology, 105 (2), 434-435. PMID: 16871089

    Carayon, P. (2006). Human factors of complex sociotechnical systems. Applied Ergonomics, 37 (4), 525-535. PMID: 16756937

    Hundt, A.S., Carayon, P., & Wetterneck, T.B. (2006). HRO characteristics as demonstrated through implementation of a smart IV pump. In Pikaar, Koningsveld, & Seffels (Eds.). Proceedings of the IEA 2006 Congress, Maastricht, The Netherlands, Elsevier Ltd.: London.

    Wetterneck, T.B., Carayon, P., Hundt, A.S., & Kraus, S. (2006). Nurses’ perception of smart IV pump technology characteristics and quality of working life. Paper presented at the IEA 2006 Congress, Maastricht, The Netherlands.

    Wetterneck, T.B., Carayon, P., Sobande, F., & Hundt, A.S. (2005). Technology characteristics predicting end user acceptance of SMArT intravenous infusion pumps. Proceedings of the Human Factors and Ergonomics Society (HFES) 49th Annual Meeting, Orlando, FL.

    Hundt, A. S., Carayon, P., Wetterneck, T. B., Love, T., Haack, B., Schroeder, M. & Enloe, M. (2005). Evaluating design changes of a smart IV pump. In Tartaglia, Bagnara, Bellandi, & Albolino, (Eds.). Proceedings of the International Healthcare Systems, Ergonomics, and Patient Safety (HEPS) Conference, Florence, Italy. Taylor & Francis: London.

    Wetterneck, T. B., Brown, R. L., Carayon, P., Kleppin, S., Hundt, A.S. & Ozkaynak, M. (2005). End-user response to intravenous infusion pump medication dosing alerts: An analysis of user-interface events. Paper presented at the Healthcare Systems Ergonomics and Patients Safety (HEPS) Conference, Florence, Italy.

    Carayon, P., Wetterneck, T.B., Hundt, A.S., Ozkaynak, M., Ram, P., DeSilvey, J., Hicks, B., Roberts, T., Enloe, M., Sheth, R., & Sobande, S. (2005). Observing nurse interaction with infusion pump technologies. In Henrikson, Battles, Marks, & Lewin (Eds.). Advances in Patient Safety: From Research to Implementation. AHRQ Publication. PMID: 21249836

    Carayon, P., Wetterneck, T. B., Hundt, A. S., Enloe, M., Love, T., Rough, S., & Schroeder, M. (2005). Continuous technology implementation in health care: The case of advanced IV infusion pump technology. Paper presented at the 11th International Conference on Human-Computer Interaction, Las Vegas, NV.

    Wetterneck, T.B., Skibinski, K., Schroeder, M., Roberts, T.L., & Carayon, P. (2004). Challenges with the performance of failure mode and effects analysis in healthcare organizations: An IV Medication Administration HFMEATM. Paper presented at the Annual Conference of the Human Factors and Ergonomics Society, New Orleans, LA.

    Carayon, P., Wetterneck, T.B., Hundt, A.S., Ozkaynak, M., Ram, P., DeSilvey, J., Hicks, B., Roberts, T.L., Enloe, M., Sheth, R. & Sobande, S. (2004). Assessing nurse interaction with medication administration technologies: The development of observation methodologies. In Khalid & Yeo (Eds.), Working with Computing Systems. Damai Sciences: Kuala Lumpar.

    Carayon, P., Wetterneck, T.B., Hundt, A.S., & Schroeder, M. (2004). Human factors in the design and implementation of patient safety technologies. Proceedings of the 15th ESCTAIC Annual Meeting, Toulouse, France.

  • BCMA Observation Form
    Pre-Implementation Pump Observation Guide
    Post-Implementation Pump Observation Guide
    Post-Pump Observation Interview Guide
    Usability Testing Script & Data Collection Guide
    Usability Testing Questionnaire – Anesthesiology
    Usability Testing Questionnaire – Nursing
    Pre-Implementation Questionnaire
    3 Months Post-Implementation Questionnaire
    One Year Post-Implementation Questionnaire
    Team Evaluation Interview Guide

    For information on observation methodology, see the following papers:

    Carayon, P., Wetterneck, T.B., Hundt, A.S., Ozkaynak, M., Ram, P., DeSilvey, J., Hicks, B., Roberts, T.L., Enloe, M., Sheth, R. and Sobande, S. “Assessing nurse interaction with medication administration technologies: The development of observation methodologies”, Presented at the WWCS’2004 Conference, Kuala Lumpur, Malaysia, June 29–July 2, 2004.

    Carayon, P., Wetterneck, T.B., Hundt, A.S., Ozkaynak, M., Ram, P., DeSilvey, J., Hicks, B., Roberts, T.L., Enloe, M., Sheth, R. and Sobande, S. “Observing nurse interaction with medication administration technologies”, Advances in Patient Safety: From Research to Implementation edited by Kerm Henriksen, James B. Battles, Eric Marks, and David I. Lewin, 2004.

    For information on the FMEA, see the following paper:

    Wetterneck, T.B., Skibinski, K., Schroeder, M., Roberts, T.L., Carayon, P. “Challenges with the performance of failure mode and effects analysis in healthcare organizations: An IV Medication Administration HFMEATM“, presented at the Annual Conference of the Human Factors and Ergonomics Society, New Orleans, LA – September 20-24, 2004.

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