Presentation
PS10 - Pump Programming Confusion: What a PETT Scan Reveals
SessionPoster Session 2
DescriptionThis proposed presentation describes a problem related to administration of intravenous medications and fluids—which is ubiquitous in inpatient healthcare—as well as the use of a sociotechnical analysis (using the people, environment, tools, and tasks [PETT] scan) to understand the complexity of this problem and to identify potential improvement opportunities.
Background: Whenever two or more intravenous infusions are simultaneously in use, there is the potential for confusion and incorrect administration of fluids and/or medications. Many of these medications are high risk, and incorrect administration could make them life threatening to patients. Despite the use of medication bar coding and "smart" pump technologies, these solutions do not prevent an incorrect infusion rate.
The introduction of multi-channel infusion pumps may increase the likelihood of an incorrect infusion rate because of the use of a central module to program settings for up to four simultaneous infusions. For example, a medication such as dexmedetomidine may be programmed to infuse at the intravenous (IVF) fluid rate, and the IVF at the dexmedetomidine rate. To understand the sociotechnical factors that might play a role in the process of safely using infusion pumps for the administration of two or more fluids/medications, a Systems Engineering Initiative for Patient Safety (SEIPS) PETT scan was performed.
Methods: Content experts from nursing, pharmacy, pediatric critical care, and unit leadership, as well as members of the safety team convened for multiple meetings to identify the sociotechnical components of use of these pumps. Through an iterative process, the team also identified interactions between the PETT scan components and factors that might serve as barriers, facilitators, or both to the process of safely using an infusion pump for two or more fluids/medications.
Results: When considering the people interacting with this process, 20 distinct groups were identified. Over 30 tasks were identified with the process, and 16 tool-related components. Each of the external, physical, and social organizational categories contained at least 10 distinct components. Many of these identified components involved interactions between two or more of the PETT scan categories.
For any given component, numerous barriers and facilitators were identified to the process of interest. Many of the barriers were also potential facilitators depending on both the context considered, as well as how the components interacted.
The results of the PETT scan were also contrasted with examples of typical patient safety event investigations to illustrate the depth and complexity revealed by the PETT scan.
Objectives:
1) Apply the learnings from our PETT scan to their own organization given many organizations use .
2) Illustrate organizational learning occurring outside of a root cause analysis given that many healthcare settings still focus on a narrow view of patient safety. Findings from this PETT scan would be compared with that from a root cause analysis, “5 Why?” methodology.
3) Exemplify to other organizations as to how they may apply the SEIPS model and the PETT tool to their own workflows.
Background: Whenever two or more intravenous infusions are simultaneously in use, there is the potential for confusion and incorrect administration of fluids and/or medications. Many of these medications are high risk, and incorrect administration could make them life threatening to patients. Despite the use of medication bar coding and "smart" pump technologies, these solutions do not prevent an incorrect infusion rate.
The introduction of multi-channel infusion pumps may increase the likelihood of an incorrect infusion rate because of the use of a central module to program settings for up to four simultaneous infusions. For example, a medication such as dexmedetomidine may be programmed to infuse at the intravenous (IVF) fluid rate, and the IVF at the dexmedetomidine rate. To understand the sociotechnical factors that might play a role in the process of safely using infusion pumps for the administration of two or more fluids/medications, a Systems Engineering Initiative for Patient Safety (SEIPS) PETT scan was performed.
Methods: Content experts from nursing, pharmacy, pediatric critical care, and unit leadership, as well as members of the safety team convened for multiple meetings to identify the sociotechnical components of use of these pumps. Through an iterative process, the team also identified interactions between the PETT scan components and factors that might serve as barriers, facilitators, or both to the process of safely using an infusion pump for two or more fluids/medications.
Results: When considering the people interacting with this process, 20 distinct groups were identified. Over 30 tasks were identified with the process, and 16 tool-related components. Each of the external, physical, and social organizational categories contained at least 10 distinct components. Many of these identified components involved interactions between two or more of the PETT scan categories.
For any given component, numerous barriers and facilitators were identified to the process of interest. Many of the barriers were also potential facilitators depending on both the context considered, as well as how the components interacted.
The results of the PETT scan were also contrasted with examples of typical patient safety event investigations to illustrate the depth and complexity revealed by the PETT scan.
Objectives:
1) Apply the learnings from our PETT scan to their own organization given many organizations use .
2) Illustrate organizational learning occurring outside of a root cause analysis given that many healthcare settings still focus on a narrow view of patient safety. Findings from this PETT scan would be compared with that from a root cause analysis, “5 Why?” methodology.
3) Exemplify to other organizations as to how they may apply the SEIPS model and the PETT tool to their own workflows.
Event Type
Poster Presentation
TimeTuesday, April 14:45pm - 6:15pm EDT
LocationFrontenac Foyer