1. technology and computing

Brigham and Women’s Hospital:
Partners in intravenous medication safety—
immediate improvement and long-term vision
Alaris products case report
®
Brigham and Women’s Hospital (BWH) is a 777-bed teaching affiliate of Harvard
Brigham and Women’s Hospital is a national leader in the use of innovative
Medical School located in the heart of Boston’s renowned Longwood Medical Area.
technology to improve medication safety. When existing infusion pumps needed to
Along with its modern inpatient facilities, BWH boasts extensive outpatient services
be replaced, the goal was to select technology that would have an immediate impact
and clinics, neighborhood primary care health centers, state-of-the art diagnostic
in averting medication errors with the greatest potential for patient harm—i.e.,
and treatment technologies and research laboratories.
intravenous (IV) medication administration errors—and fit with BWH’s long-term
BWH employs more than 12,000 people, with more than 3,000 Physicians, Fellows
and Residents, more than 1,000 Researchers, 2,800 Nurses and 66 Department
Pharmacists. BWH cares for approximately 44,000 inpatients and 950,000
outpatients annually, with 54,000 Emergency Department visits. New England’s
largest birthing center, and a regional leader in high-risk obstetrics and newborn
care, more than 9,000 babies are born at BWH, and more than 1,300 infants are
treated in the Newborn Intensive Care Unit.
Named one of America’s Best Hospitals 18 years running
Alaris
®
vision of an integrated medication administration system (MAS).
A research trial in cardiovascular surgery intensive care and step-down units, minitrials involving regular clinical use in medical intensive care and hematology/oncology
units, simulations and visits to other hospitals were used to evaluate the Alaris
System. After studying this issue and various technologies for more than a year, BWH
selected the Alaris System with Guardrails ® Suite MX software for hospital-wide
implementation, based on technology, safety and future consideration as part of a
totally integrated system.
“ If you only have $1 million, what do you do? Implement technology
that would stop some of the most serious errors. Implementing the
Alaris System hospital-wide is the quickest thing we’ve ever done
to improve patient safety. Usually it takes five years, minimum,
to make change in a big organization. Nurses are actually using
this technology, and the data show that over time they’re using it
more. It’s averting high risk errors and allowing us to monitor and
improve best practices.
I didn’t think the CQI data would be so powerful. The first time we
presented the data spreadsheets, jaws dropped, ‘My god, if that
had gotten through.’ Now you can see what you always knew was
there. CQI is the pearl in the oyster.”
Judy Hayes
Director or Professional Practice
Key deciding factors
• Speed to impact—relatively low cost, rapid implementation and immediate
impact on medication safety
• The Alaris System with the Guardrails Suite MX software is information
technology—a computer at the bedside, not just a pump
• A single platform for multiple devices, future developments and connectivity
improves safety, reduces training needs and fits long-term vision
• Drug libraries provide the best of both worlds—a device that can be used in
any unit, yet customized for the particular unit where being used
• Continuous quality improvement (CQI) logs provide real, actionable data
Implementation
• The Alaris System with Guardrails Suite MX software
• 900 Alaris PC units, 1,700 modules
“ You’ve got the capability with this technology to drive safety
standards immediately and over the long term. A customized
library will cue clinicians in real time if they are making a common
and very human mistake, such as programming an incorrect
rate because they were distracted. The CQI allows leadership to
identify practice patterns and opportunities for education.”
Cathy Saniuk, CNS
Critical Care Program Coordinator
“The Alaris System helps to provide an extra level of safety to
Nurses as they work hard to meet the complex needs of today’s
hospitalized patients. The decision support software provides
additional reassurance that medications will be programmed
• Hospital-wide implementation
• Data set customization, staff training, product set-up and go-live installation
were completed in approximately 65 days
• Implementation required no additional FTEs
• Go-live installation was completed in approximately 12 hours with a team
of people from Materials Management, Pharmacy, Biomedical Engineering,
Nursing and Alaris SmartServiceSM implementation
Performance
Initial research data from use of the earliest version of the software identified
compliance issues. Compliance in regular clinical practice improved to excellent
following two quality improvement efforts:
1) Staff training improved the “culture of use.”
correctly, thus minimizing the risk of intravenous
2) Collaboration with the CareFusion, Alaris products team led to drug library
administration errors.”
refinements and upgraded software that addressed human factors through a
more natural “mapping” of the IV infusion therapy that is closer to BWH’s best
Carol Keohane, RN
Research Coordinator, CareFusion, Alaris products trial,
BWH Center for Excellence
practice and thus easier to use. Compliance has steadily improved and Nursing
acceptance is excellent.
Conclusion
• Assisting the Clinical Nurse at the point of care with readily available
information regarding drug dosing and potential drug errors provides a
patient safety improvement tool for the entire organization
• This technology allows clinicians to catch an error before the incident report
• The power of this kind of change—implementing IV medication safety
systems—is that the patient is at the center of the change
• Opportunities for improvement from using the CQI data are abundant—the
power of the data becomes apparent once the data are analyzed
• Ideally, as wireless connectivity integrates all components of the medication
administration system, we will have the ability to eradicate errors
“Smart IV infusion systems have great
potential to reduce serious and lifethreatening medication errors. Nurses
who have used the Alaris System and
have had a significant error—such as a
100-fold heparin overdose—intercepted
are sold the rest of their career. They
believe in the system. They’re going
to use the library. This is a
valuable technology.”
Jeffrey Rothschild, MD
almost entirely
“As part of our overall medication safety
Results
strategy at Brigham and Women’s
Initial CQI data show that the Alaris System has averted IV administration errors
one of the early computerized prescriber
that would have been significant, had they not been averted by the safety
order entry (CPOE) systems in hospital
software, for example:
use. We showed that it reduced the
• 100 mg of morphine reprogrammed to 5 mg
serious medication error rate, but
• Heparin errors with extra zeros
many errors remained, particularly
• 705 mg of insulin reprogrammed to 7.5 mg
administration errors. Intravenous
• Potential amiodarone errors that clearly show confusion between bolus,
administration errors are particularly
peripheral and central infusion rates
Hospital, we developed and evaluated
serious, and our desire to prevent these
Typical near misses include extra zeros, missing or misplaced decimal points,
errors led to hospital-wide implementation of the Alaris System with
transposition of rate and dose (mL and mg) and 10- and 100-fold errors.
the Guardrails Suite MX software. Key factors were the system’s
‘speed to impact,’ error prevention and data-collection capabilities,
and platform for future safety innovations and wireless networking.
Unique continuous quality improvement (CQI) logs are providing a
treasure trove of information, and allow us to measure, impact and
identify process improvements in ways never before possible.
David Bates, MD
CareFusion
San Diego, CA
carefusion.com
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