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.
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
2010
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
2009
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
2008
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.
2007
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.
2006
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.
2005
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.
2004
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.