Application of the IV Medication Harm Index to Assess the Nature of Harm Averted by "Smart" Infusion Safety Systems

Abstract

Objectives: To apply the new IV Medication Harm Index to continuous quality improvement data to assess the nature of harm averted by infusion-safety systems. Methods: The IV Medication Harm Index (score range, 3.5 to 14; higher scores indicate greater harm/risk) was applied to analyze data on averted intravenous medication errors gathered from 426 "smart pumps" (computerized infusion devices with dose-error reduction software) during a 9-month period at 2 tertiary-care hospitals. Results: Of 166 averted overdoses, 100 (60.2%) involved high-risk medications, and 105 (63.3%) were medications unlikely to be detected in the event of overdose. IV Medication Harm Index scores ranged from 3.5 to 13 (mean, 8.2; range, 3.5 to 14), and 33 (19.9%) averted overdoses scored 11 or higher. Sorted by frequency only, propofol, heparin, and dopamine accounted for more than half of all averted overdoses; however, IV Medication Harm Index analysis showed that heparin and propofol accounted for almost three-quarters of the highest-risk averted overdoses. More than three-quarters of the pumps were used with adult critical care patient types; more than half of the highest-risk averted overdoses occurred with non-intensive care unit (ICU) patient types. Results led to several practice improvements for the highest-risk-for-harm drugs. Conclusions: Findings suggest that the IV safety systems averted significant harm and that the IV Medication Harm Index provides the ability to filter large pools of data to reveal events with the greatest potential for causing harm, so these can be studied and acted on first, which is likely to have the greatest impact in improving medication safety.