How to prevent error? Cut your process in half

By ThinkReliability Staff

Congratulations to Lancaster General Hospital, who received the Best Practices Award In Health-System Pharmacy yesterday (December 7, 2009).  The award was to recognize the hospital’s success in auto-programming of infusion pumps.  As Lancaster’s Medication Safety Pharmacist Amanda Prusch has stated:

Auto-programming provides an additional layer of safety than the stand-alone technologies and by streamlining the IV medication administration process, the potential for error would be reduced.

Lancaster identified a problem – in this case the problem is medication errors, of which 56% are estimated to be from improperly inserted intravenously (I.V.) medications.  Because of the potential for serious adverse patient health outcomes due to medication errors, Lancaster knew something had to be done.  Lancaster looked at the infusion pump programming process, and discovered it had 17 steps, many of them manually performed.  At each manually-controlled step in a process is an opportunity for human error, no matter how careful people are.

By reducing the number of steps in a process, and by reducing the amount of human input required, the opportunity for human error is reduced.  In order to reduce this risk, Lancaster has implemented “fully auto-programmed smart infusion systems” .  The implementation of these systems has reduced the number of steps in the infusion pump programming process to 7 (from 17).  As a result, they have seen a greater than 90% reduction in reprogramming (or errors that were noticed and fixed).  This has surely led to a great reduction in I.V. medication administration errors.  In addition to the patient safety improvements, it has the added bonus of reducing the amount of time spent programming the pumps by 24.8%.  This also contributes to patient safety because it frees up nurses’ valuable time.

Read more about the new infusion pump system.   Lancaster’s solution is just one way to solve the problem of medication errors.  However, by removing steps from a process, not only does it require less time of your most valuable asset (employees), it can reduce the possibility for error.