Pump Up the Volume

This blog is a little different. My hospital has asked me to produce a themed blog related to a series of incidents we have had across a number of different acute specialties. Some of the links point to local 'in house material' so I apologise in advance if you can't see them. Your hospital will have something similar or perhaps better.....if you do let me know.
However it doesn't really matter if you are an EM type or a PICU nurse the messages are still the same.

Pump Action

Modern hospital medicine requires the delivery of a number of, well lets face it potentially dangerous chemicals, directly into a patient's veins or tissues many thousands times of day. To help us do this more accurately we rely very heavily on variety of  syringe driver devices and pumps. This of course has been a great step forward in patient safety. 
To get to the position we enjoy now, highly technical pieces of kit and smart pumps, has not been an easy journey. Hands up who knew that the first described IV infusion into an animal was performed by Sir Christopher Wren in 1656 who developed

 ‘a way to convey liquid poison into the mass of blood’. 

He fashioned a quill and a pig’s bladder to instill wine, ale, opium and liver of antimony into a dog’s veins. An intoxicated dog was the 'successful' endpoint.

For those of you keen to know more about some of the dubious practices that have lead us to today's relative IV nirvana try this IVI History or driver inventor 

I promise you at least one Pope, quite a lot of death and several unfortunate animals. 

Sadly where humans go, errors follow, and even more sadly patients have come to harm as a result.

The National Picture

In the five years between 2005 and 2010 the Medicines and Healthcare products Regulatory Agency (MHRA) investigated 1,085 incidents involving infusion pumps alone in the UK. In 68% of the reports no cause was established (either due to reporting error or the device was working as intended), 11% of incidents were due to device error but 21% were attributed to user error.
MHRA and pumps

Locally

Below you will find real cases where patients have been damaged, or potentially damaged by pump or infusion errors. As always theses cases are not here to vilify the unfortunate health care professionals involved but to show you what can happen with real patients in real hospitals and what real harm can result.

If you know about what can go wrong, you are in a far better place to avoid making the same mistake. Learn from others mistakes, don't wait for your own.

Give Me Five

A patient with pre-existing vascular disease came into the ED with status epilepticus (continuous seizures). Standard therapy failed to stop the fitting activity. The correct call was made to rapidly paralyse and anaesthetise the patient (RSI) and place them on a breathing machine (ventilator). The on-call anesthetist was unfamiliar with the ED Resus room so correctly asked for support. An ODP came down from theatres bringing a syringe driver infusion pump with him, for which he drew up 50 ml of 2% propofol from the ED stock.

The patient was successfully anaesthetised and the syringe pump was connected to the patient with the propofol in place.  A verbal order was given by the anaesthetist to 'start the rate at 5mL/hr' and the rest of the patient's care continued.

Approximately 15 minutes later the patient became hypotensive and unstable. They required adrenaline boluses and further intravenous fluids to maintain their blood pressure. An ultrasound of their heart showed global hypokinesia (poor pumping). At this point the syringe pump alarmed and it was noted to have delivered the entire 50 ml of propofol in the preceding 30 minutes. The patient's blood pressure dropped to 50/? before a cardiac arrest occurred.  Life support protocols were followed and a pulse was restored after one cycle of CPR and further adrenaline.

In the following hours the patient was stabilised on ICU but did develop heart failure for which they were successfully treated. They subsequently were found to have suffered a Non STEMI (heart attack) almost certainly caused by the period of severe low blood pressure. Sadly they also developed an ischaemic limb which required amputation. This too was felt to have been contributed to by the  low BP and decreased heart pump function.

Unsurprisingly a Serious Incident report was generated.

So what happened?

The patient had lots of good care. The ambulance service followed their protocols correctly, the ED initial work up and management were correct. The plan to 'tube and vent' was correct. The initial RSI was safe and secure.  The maintenance of anaesthesia was the issue.  Additionally as soon as the error was discovered a serious incident was declared and the pump removed and stored for later investigation.

So what went wrong?

The theatre pump that had been connected to the patient was set to run at 5 mg/hr not 5 mL/ hr. 

The pump used in this case has a number of 'smart functions' to allow weight based calculations for drug delivery.  This requires a number of data points to be entered, but when the pump is turned on it defaults to its previous settings. In this case 5mg/hr of  50 micrograms/ml drug concentration, which gives  a rate of 100mL/hr.

Other factors?

The ED staff involved were not familiar with the 'smart pump' device only using devices with a default mL/hr setting.

The documentation around the anaesthetic and maintenance infusion was minimal at best, with no prescription being written or checked. (Clearly in urgent situations this can be unavoidable, but should be done retrospectively)

What did we learn?

The final responsibility for ensuring the correct drug is correctly prescribed, drawn up, connected and delivered remains the responsibility of the doctor in charge of that specific procedure/treatment.

A second independent check of all of these elements is mandatory.

However single handed clinicians in operating theatre environments this may not always be practical but is considered good practice

The injectable medicine code is being reviewed to reflect the emergency work carried out by anesthetists and others outside a theatre setting

If you haven’t been trained to use a specific pump, don’t touch one.

Switch Hitting

A patient was admitted to critical care following a very long and complex operation to repair an acute aortic dissection. The patient was on IV adrenaline, IV noradrenaline, IV dopamine, to support the patient’s blood pressure and also on IV aprotinin to help reduce post-operative bleeding. 

On the instruction of the Consultant Surgeon the patient’s blood pressure was to be no higher than 120 systolic. A couple of hours into their admission the patient had a surge in blood pressure to 200 systolic. All blood pressure raising drugs were stopped and a bolus of IV labetolol 5mgs was given to try to reduce this surge. The blood pressure reduced to 105 systolic. Further labetolol was given before an infusion of labetolol was commenced.

An hour or so later the patient’s blood pressure dropped to 45 systolic and they were noted have bleed 200mls into a surgical drain. Full CPR was started before the patient ‘s return to theatre for emergency re-sternotomy & exploration.

Subsequently it was discovered that the syringe containing adrenaline had been placed in the pump for the aprotinin.  The adrenaline was prescribed at 5mls an hour, the aprotinin at 50mls an hour. As a result they received 4.5mg of adrenaline not 0.45mg, resulting in the blood pressure spike and subsequent complications.

Good Care & What Went Wrong?

The drugs were drawn up, labelled and checked correctly.  Unfortunately the syringes were not checked into the correct driver or the rates confirmed by two trained staff.

When the patient became unwell the response of the clinical teams was appropriate. The incident was reported immediately and shared with the family. The pumps involved were all removed from clinical use and sent to Medical physics for scrutiny. Additionally an immediate critical care safety alert to prevent recurrence was sent out.

Learning Bite

The lesson to learn here is best summed up by the Critical Care alert;

‘two registered nurses must be involved in all aspects of the  infusion preparation and administration process up to and including insertion of the syringe into the syringe driver’

Aortic Dissection on Up-to-Date

The Trouble with Double

All medics and nurses will be familiar with the concept of double checking prescriptions and infusions prior to delivering them to the patient. It's a fail safe belt and braces right?

Well actually no.  There is evidence that it can sometimes contribute to drug errors IF it is not carried out properly and rigourously. Double checking medicines: defence against error or contributory factor?

 Here are four possible explanations;

-deference to authority

            ‘they know what they’re doing, I can relax’

-reduction of responsibility

            ‘I don’t need to read it properly, they are’

- automatic processing

            Eyes are open but no one is home

-lack of time

            Rushing

A safer way of avoiding error is 'independent checking' This consists of two individuals checking each element of the infusion independently and in isolation from each other. That is the two staff do not stand side by side checking each other checking the infusion ..... They check the infusion.

Further guidance to this can be found locally in the medicines code , here in the injectable medicine code

Theres also a good overview on independent checking from our American Cousins 

Unfortunately no system is fail safe if those carrying it do not do so with appropriate care

Frequent Little Things

There are several common themes in our reported pump errors….

Are You Concentrating?

A sick baby required blood pressure support with Dopamine at 10micrograms/kg/min. A syringe driver was drawn up containing 60mg of the drug in a 1,200 microgram/mL solution. However when prompted during set up, the concentration entered into the driver was 2,400microgram/mL. As a result the baby received half the dose that the team believed they were getting.

Another small child was on a midazolam infusion. At shift change safety check it was noted that the child had been receiving 66mg in 50ml rather than the prescribed 33mg in 50mL and as a result was receiving too much drug.

Neither child came to significant harm

Learning Bite

In both cases the infusions were drawn up and delivered with a signed off double check at each stage. This does not make those individuals ‘bad’. There was no deliberate error here.

The mistake was in believing that the act of double checking works well in itself. It doesn’t.

It only works if both parties concentrate and feel capable of questioning the other.

‘It’s Ok to ask’

A Matter of Rate x3

1- A stroke patient undergoing thrombolysis was transferred to the angio suite for clot retrieval. During

transfer the pump ran out of battery and turned itself off. In the angio suite the pump was restarted on mains power by a different member of staff who asked the Brain Attack Team what rate to run it at.

Once restarted the pump was then out of sight of the BAT team behind sterile drapes. Half way through the procedure the BAT nurse managed to look at the pump from a distance and noticed that the syringe instead of being nearly empty as expected was still nearly full.
The pump had been restarted at 0.53mls/hr not 53mls/hr.

2- A patient with abdominal pain required an infusion of C1-esterase inhibitor. Prior to transfer to a ward it was noted that the syringe seemed fuller than expected.  The pump had been set at 6mls/hr not 60mls/hr

3- A patient with heart failure on the ward required a furosemide infusion over 24 hours. After a few  hours the pump alarm sounded. On inspection the infusion was complete having been set to run at 41.7mLs/hr not 10.4mLs/hr

Again no serious harm resulted from any of these cases but this was more by luck than judgment and clearly we could have done things better.

Learning Bite

All rate changes to infusions should be checked, documented and signed.

If you haven’t been trained to use a specific pump, don’t even touch it.

If you are unfamiliar with the drug being given in pump, don’t change anything until you have found someone who is.

The Silence of the Alarms

A patient was on a post-operative Insulin-glucose sliding scale. During the ward round the insulin was noted to be running at the minimum ‘keep vein open’ rate of 0.5mL/hr, but the dextrose was left running at 80mLs/hr. The alarm on the insulin pump had been silenced.

Unsurprisingly the patient’s blood sugar was found to be higher than desirable. They required additional insulin and closer monitoring than planned but fortunately came to no serious harm

Learning Bite

Alarms are there for a reason.

When they go off, check why and act on the result.

Avoid ‘alarm fatigue’ by good cannula siting and infusion management

Summary

So pumps really are great. They make a massive contribution to delivering safe effective care to our patients every hour of every day.

However like all machines the still require humans to tell them what to do.

If the human bit goes wrong, so does the infusion...... and catastrophic harm can result.

Reduce your risk of harm by independent checking of all stages of pump/infusion prescription, solution mixing, rate setting and connection to the patient.

Learn from the mistakes of others, don't wait until next time, it could be you.... on either end of the infusion.

Here's a handful of some of the great people I get to work with each day

Think Pump. Think safety

Gratuitous Nonsense Link- For 1980's retronauts everywhere