IJNHCR Journal

In the US, 7,000 to 9,000 patients die each year due to medication errors [1]. More than 50% of serious and life-threatening medication errors are due to intravenous (IV) medications [2]. Smart infusion pumps with dose error-reduction systems (DERS), such as the BD Alaris^™ Guardrails^™ Safety Software (AGSS), along with associated drug libraries are utilized to decrease IV medication errors [3]. One of the primary safety features of DERS is drug libraries as well as hard and soft rate limits. Drug libraries are a set of pre-programmed lists of medications, set by the institution, for specific patient care areas. The goal of having drug libraries is to minimize the amount of irrelevant medications to decrease the chances of medication errors. Hard limits are rates that cannot be bypassed and prevent excessive rates from being initiated. Soft limits warn the user that the rate is outside the expected range but still allow the infusion to start as programmed. All Guardrail limits may be bypassed altogether using the basic infusion mode.

In 2020, the Institute for Safe Medical Practices (ISMP) set a compliance rate goal of ≥95% for using dose error-reduction systems [4]. The ISMP conducted two surveys on the use of smart infusion pumps as well as challenges for implementation [5]. The first survey found that the most common errors in using the smart pump were secondary infusions delayed/omitted due to roller clamps being closed, dose-rate confusion during pump programming, wrong rate errors for secondary infusions, and IV line or channel mix-ups [6] The second survey questioned only front-line nurses and their errors were similar to the previous survey [7]. The most common errors were the secondary infusion being delayed/omitted due to the roller clamp being closed, doserate confusion, and wrong rate errors for secondary infusions.

Williams I. conducted a pre- vs post-survey on the use of the AGSS after several organization-wide interventions. The interventions include smart pump training at orientation, updating drug libraries quarterly, a pump champion program, and continuous monitoring. This study showed an increased rate of compliance after the interventions, 63% to 88%, and a decrease in medication errors, 1108 events to 235 events. These interventions were successful in increasing the compliance rate, however, they were not at the ISMP goal of ≥95% compliance. Several barriers they remained post-intervention were that the drug was not found in the Guardrails TM library, the nurse did not have enough time to use the Guardrails ^TM /the Guardrails ^TM is tedious, and existing Guardrails ^TM settings do not match with workflows in their care areas.

University Medical Center New Orleans (UMCNO) has set a benchmark of 90% compliance rates for the utilization of Guardrails^™. Currently across all units at UMCNO, the average monthly compliance rate is 78%. The purpose of this study was to identify barriers to the use of Guardrails^™ among nursing staff with the future goal of implementing future changes to increase compliance across all units.

Methods

All fourteen survey questions were developed with the intent to broadly target potential factors that may influence a nurse’s decision when deciding to operate outside of AGSS. Questions were also designed to capture the years of experience as an RN and tenure at UMCNO. After the questions were developed, a screening process was undertaken to validate the survey questions’ applicability to a registered nurse’s workflow. Questions were first screened by the UMCNO Department of Pharmacy research committee, followed by nursing leadership from planned participating units. The pharmacy research committee and nursing unit leaders were given the opportunity to screen prospective questions and provide feedback prior to the Institutional Review Board (IRB).

This was a single-center, institutional-based cross-sectional study of all nursing staff at UMCNO. The site is a 446-bed, safetynet, research, and academic hospital. This study was approved by the IRB-Louisiana State University Health Sciences Center as well as by the  UMCNO Office of Research (states Research Office). From August 9, 2022, to October 14, 2022, an electronic survey was distributed to all nursing staff about their utilization and potential barriers to the AGSS. Nurses either scanned a Quick Response (QR) code or entered a link to a survey on Microsoft Forms, where they entered anonymous responses. Included in the survey were nurses who worked at UMCNO. Those that were excluded from the survey were nurses who only worked in the Emergency Department (ED) as well as nursing students and certified nursing assistants. Nurses who only worked in the ED were excluded because of the high rate of bypassing the Guardrails^™ due to emergent scenarios. If a nurse worked in the ED as well as another unit (e.g. ED + medical floor), they would be included.

Survey

An electronic, 14-question survey was distributed to all nursing staff. The survey was distributed by handouts and e-mail. Nurses accessed the survey by scanning a quick response (QR) code or entering the link to Microsoft Forms. The analyzed responses were categorized into 3 units, intensive care unit (ICU), general floor, and procedural areas. The intensive care unit consisted of the burn ICU, medical ICU, and trauma ICU. The general floor consisted of the medical/surgical floors, the observational unit, and the controlled access unit (prison unit). The procedural areas consisted of the inpatient oncology, operating room, outpatient infusion, outpatient oncology, outpatient surgery, and postanesthesia care unit (PACU).

The electronic survey was categorized into 2 major groups. Questions 1-5 are baseline characteristics looking at nursing credentials, total years practiced, years practiced at UMCNO, employment status, and unit assignment. Questions 6-14 aim at identifying barriers to the AGSS and are further divided into subgroups. Questions 6 and 7 assess the nurse’s background knowledge and education on the AGSS. Questions 8-9 asses the nurse’s response and reason for using the basic infusion mode. Questions 10-11 assess communication between nurses.

Questions 12 - 14 assess programming barriers.

Endpoints

The primary endpoint was to identify potential barriers affecting the utilization of Alaris™ Guardrails™ Safety Software. The secondary endpoints were to identify unit-specific trends of compliance non-compliance and barriers to utilization. For the unit-specific trends, only the ICUs and general floor were included in the secondary analysis. Responses from the procedural areas group were excluded from unit-specific trends due to differing practice patterns with the use of the AGSS. Results from the primary and secondary endpoints were analyzed using descriptive statistics.

Results

Study Participants

From August 9, 2022, to October 14, 2022, 157 survey responses were collected. Of the collected responses, a total of 152 responses were assessed with the other five responses being excluded due to the participants only working in the emergency department. The majority of staff nurses were credentialed as “registered nurses” (90.8%), with a total of 1-5 years of practice experience in both total years (40.1%) as well as years at UMCNO (48%). In terms of employment status at UCMNO, the majority of participants worked full-time (71.1%). Part-time employees made up 15.1% of responses and contract employees made up 13.2%. For survey responses, there was a comparable number of responses amongst the general floor (44.1%), ICU (37.9%), and “other” units (18%). Of note, there were no reported survey responses from several areas such as outpatient infusion, outpatient oncology, and outpatient surgery.

Survey Responses Background knowledge and education

Most nurses knew the difference between the Guardrails ^TM mode and the basic infusion mode (83.6%). In terms of the last formal training, 24.8% of respondents had not received or were unsure of their last training session for the AGSS and 24.3% of respondents had not been formally trained in over one year.

Response for using the Basic Infusion mode.

If a nurse cannot find a medication in the drug library, the top responses were that they would utilize the Basic Infusion mode and notify the pharmacy (34.5%), ask another nurse for assistance (31.8%), or contact the pharmacy for assistance before choosing the Basic Infusion mode (27.8%). Most nurses claimed to have bypassed the AGSS in the past year, with less than half never bypassing the Guardrails^TM mode and using the basic infusion mode (40.8%).

Communication between nurses

The majority of respondents answered that they always tell the oncoming nurse when the Basic Infusion mode is being utilized (51.3%). On the contrary, most nurses said that they have never been informed if the Basic Infusion mode is being used at shift change (61.8%).

Possible programming barriers

The most common reason for a nurse to override the AGSS was being unable to find the medication in the drug library (27%) followed by the ordered rate being above or below the soft limits (21.5%). The most common overridden medication was maintenance fluids (39.8%). A majority of respondents never had the drug library loaded incorrectly in the past year (52.6%).

Unit-specific trends