Medication Error Reduction, Technologies & Human Factor

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DESCRIPTION (provided by applicant): Technology has been used to decrease medication errors throughout the medication use process. However, implementation of technology with a prospective approach using human factors techniques to smooth the transitions is not routinely used. Instead, failures in implementation and new errors have occurred. The medication administration process has few double checks in the process and new technology is available to decrease errors. Intravenous medication errors directly reach the patient and are among the most serious medication errors. Smart IV pumps have predefined medication dose limits and their integration with bar code technology may be the ultimate defense for infusion errors. This study proposes to evaluate the implementation of Smart IV pumps and their integration with a bar code medication administration system in a large University Hospital. The technologies have the ability to decrease medication administration errors and also change nurses' and other end users' worklife. For that reason, the human factors approach with prospective error analysis will be used to evaluate the technology and technology change process; specifically utilizing failure mode and effects analysis, work system analysis and technology change surveys to improve implementation. Direct observations, surveys and longitudinal assessment of the Smart IV pump event log data and error reports will provide rich data on IV pump programming errors and provider job and worklife characteristics affected by the change process. This study will provide hospitals without medication administration technology opportunities to assess and change human, medication and organizational factors related to pump programming errors. Valuable information will be gained and shared about the technology change process associated with Smart IV pump implementation and integration with a bar code medication administration system to allow other hospitals to safely and effectively implement these technologies and avert new errors.