Journal of Pediatric Nursing
Volume 25, Issue 2 , Pages 108-118 , April 2010

Impact of Computerized Orders for Pediatric Continuous Drug Infusions on Detecting Infusion Pump Programming Errors: A Simulated Study

  • Azizeh K. Sowan, PhD, RN

      Affiliations

    • School of Nursing, Hashemite University, Zarqa, Jordan
    • ,
  • Mohamed I. Gaffoor, MD

      Affiliations

    • Department of Pediatrics, Maimonides Medical Center, NY
    • ,
  • Karen Soeken, PhD

      Affiliations

    • School of Nursing, University of Maryland, MD
    • ,
  • Meg E. Johantgen, PhD, RN

      Affiliations

    • School of Nursing, University of Maryland, MD
    • ,
  • Vinay U. Vaidya, MD

      Affiliations

    • Department of Pediatrics, School of Medicine, University of Maryland, MD
    • Corresponding Author InformationCorresponding author: Vinay U. Vaidya, MD.

References 

  1. Adachi W, Lodolce A. Use of failure mode and effects analysis in improving the safety of i.v. drug administration. American Journal of Health-System Pharmacy. 2005;62:917–920
  2. American Academy of Pediatrics . Policy statement: Prevention of medication errors in the pediatric inpatient setting: Committee on Drug and Committee on Hospital Care. Pediatrics. 2003;112:431–436
  3. Bailey J. Development of an instrument for the management of computer use attitudes in hospitals. Methods of Information in Medicine. 1990;29:51–56
  4. Bates D, Cullen D, Laird N, Petersen L, Small S, Servi D, et al. Incidence of adverse drug events and potential adverse drug events: Implications for prevention. Journal of the American Medical Association. 1995;274:29–34
  5. Bates D, Leape L, Cullen D, Laird N, Petersen L, Teich J, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Journal of the American Medical Association. 1998;280:1311–1316
  6. Bayne T, Bindler R. Effectiveness of medication calculation enhancement methods with nurses. Journal of Nursing Staff Development. 1997;13:293–301
  7. Calliari D. The relationship between a calculation test given in nursing orientation and medication errors. Journal of Continuing Education in Nursing. 1995;26:11–14
  8. Cordero L, Kuehn L, Kumar R, Mekhjian H. Impact of computerized physician order entry on clinical practice in a newborn intensive care unit. Journal of Perinatology. 2004;24:88–93
  9. Fanikos J, Fiumara K, Baroletti S, Luppi C, Saniuk C, Mehta A, et al. Impact of smart infusion technology on administration of anticoagulants (unfractionated heparin, argatroban, lepirudin, and bivalirudin). American Journal of Cardiology. 2007;99:1002–1005
  10. Grandell-Niemi H, Hupli M, Leino-Kilpi H, Puukka P. Medication calculation skill of nurses in Finland. Journal of Clinical Nursing. 2003;12:519–528
  11. Gurwitz J, Field T, Harrold L, Rothschild J, Debellis K, Seger A, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. Journal of the American Medical Informatics Association. 2003;289:1107–1116
  12. Herout P, Erstad B. Medication errors involving continuously infused medications in a surgical intensive care unit. Critical Care Medicine. 2004;32:428–432
  13. Husch M, Sullivan C, Rooney D, Barnard C, Fotis M, Clarke J, et al. Insights from the sharp end of intravenous medication errors: Implications for infusion pump technology. Quality & Safety in Health Care. 2005;14:80–86
  14. Institute for Safe Medication Practice . Design flaw predisposes Abbott Lifecare PCA Plus II pump to dangerous medication errors. Retrieved December 1st, 2007 from http://www.ismp.org/Pages/Lifecare.html2000;
  15. Institute for Safe Medication Practices . ISMP's list of high-alert medications. Retrieved, February 25, 2008 from http://www.ismp.org/Tools/highalertmedications.pdf2005;
  16. Kaushal R, Bates D, Landrigan C, McKenna K, Clapp M, Federico D, et al. Medication errors and adverse drug events in pediatric inpatients. Journal of the American Medical Association. 2001;285:2114–2120
  17. Larsen G, Parker H, Cash J, O'Connell M, Grant MC. Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005;116:21–25
  18. Leape L, Bates D, Cullen D, Cooper J, Demonaco H, Gallivan T, et al. Systems analysis of adverse drug events. Journal of the American Medical Association. 1995;274:35–43
  19. Lee F, Teich J, Spurr C, Bates D. Implementation of physician order entry: User satisfaction and self-reported usage patterns. Journal of the American Medical Informatics Association. 1996;3:42–55
  20. Lehman CU, Kim GR, Gujral R. Decreasing errors in pediatric continuous intravenous infusions. Pediatric Critical Care Medicine. 2006;7:225–230
  21. Lesar T. Errors in the use of medication dose equations. Archives Pediatrics & Adolescent Medicine. 1998;152:340–344
  22. Mekhjian H, Kumar R, Kuehn L, Bentley T, Teater P, Thomas A, et al. Immediate benefits realized following implementation of physician order entry at an academic medical center. Journal of the American Medical Informatics Association. 2002;9:529–539
  23. Mitchell A, Sommo P, Mocerine T, Lesar T. A standardized approach to pediatric parenteral medication delivery. Hospital Pharmacy. 2004;39:433–459
  24. Nicholas P, Agius C. Toward safer IV medication administration: The narrow safety margins of many IV medications make this route particularly dangerous. American Journal of Nursing. 2005;105:25–30
  25. Nuckols T, Bower A, Paddock S, Hilborne L, Wallace P, Rothschild J, et al. Programmable infusion pumps in ICUs: An analysis of corresponding adverse drug events. Journal of General Internal Medicine. 2007;23(Suppl 1):41–45
  26. O'Connell R, Cho C, Shah N, Brown K, Shiffman R. Take note(s): Differential EHR satisfaction with two implementations under one roof. Journal of the American Medical Informatics Association. 2004;11:43–49
  27. Puangco M, Nguyen H, Sheridan M. Computerized PN ordering optimizes timely nutrition therapy in a neonatal intensive care unit. The Journal of the American Dietetic Association. 1997;97:258–261
  28. Rich, D. (2003). Ask the Joint Commission: More on the requirements of the medication-related National Patient Safety Goals for 2003–2004. Hospital Pharmacy, 38; 977–980, 989.
  29. Rosenbloom T, Talbertc D, Aronsky D. Clinicians' perceptions of clinical decision support integrated into computerized provider order entry. International Journal of Medical Informatics. 2004;73:433–441
  30. Ross L, Wallace J, Paton Y. Medication errors in a pediatric teaching hospital in the UK: Five years operational experience. Archives of Disease in Childhood. 2000;83:492–497
  31. Rothschild J, Keohane C, Cook EF, Orav E, Burdick E, Thompson S, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Critical Care Medicine. 2005;33:533–540
  32. Stratton K, Blegen M, Pepper G, Vaughn T. Reporting of medication errors by pediatric nurses. Journal of Pediatric Nursing. 2004;19:385–392
  33. Taxis K, Barber N. Ethnography study of incidence and severity of intravenous drug errors. British Medical Journal. 2003;326:684
  34. U.S. Pharmacopeia . In: Seniors are at risk for medical errors in hospitals. Vol. 29:01:2004;Retrieved, March 25, 2008 from http://www.uspharmacist.com/index.asp?show=article&page=8_1198.htm
  35. Vaidya V, Gaffoor M, Hilmas E, Mathews L. A computerized program for changing from rule of six to standardized drips. In: Poster Presentation at the Pediatric Critical Care Colloquium. 2004;
  36. Vanderveen T. IVs first: A new barcode implementation strategy. Patient Safety and Quality Healthcare. 2006;3:14–20
  37. Weiner M, Gress T, Thiemann D, Jenckes M, Reel S, Mandell S, et al. Contrasting views of physicians and nurses about an inpatient computer-based provider order entry system. Journal of American Medical Informatics Association. 1999;6:234–244
  38. Wilson D, McArtney R, Newcombe R, McArtney R, Gracie J, Kirk C, et al. Medication errors in pediatric practice: Insights from a continuous quality improvement approach. European Journal of Pediatrics. 1998;157:769–774
  39. Wilson K, Sullivan M. Preventing medication errors with smart infusion technology. American Journal of Health System Pharmacy. 2004;61:177–183

☆ Previous presentations: (a) Sowan, A., Gaffoor, M., Soeken, K., Mills, M. E., Johantgen, M., et al. (2006, November). A comparison of medication administration errors using CPOE orders vs. handwritten orders for pediatric continuous drug infusions. Abstract presented at the American Medical Informatics Association Annual Symposium, Washington, DC. (b) Sowan, A., Soeken, K., Hilmas, E., Gaffoor, M., Mills, M. E., et al. (2006, July). The effect of computerized orders with standardized concentrations for continuous infusions on medication administration errors. Abstract presented at the 16th Annual Summer Institute in Nursing Informatics, University of Maryland School of Nursing, Baltimore, MD. (c) Sowan, A., Gaffoor, M., Soeken, K., Johantgen, M., Hilmas, E., et al. (2006, January 7–11). The effect of a computerized order entry (CPOE) system for the use of continuous medication infusions on nursing efficiency and error-reduction. Abstract presented at the Society of Critical Care Medicine's 35th Critical Care Congress, San Francisco, CA.

PII: S0882-5963(08)00403-X

doi: 10.1016/j.pedn.2008.10.002

Journal of Pediatric Nursing
Volume 25, Issue 2 , Pages 108-118 , April 2010

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