Presentation
PS1 - Applying Human Factors to a Medication Free Flow Mitigation Strategy for a Hospital’s OR, PACU, and CVICU
SessionPoster Session 1
DescriptionThe purpose of this project was to assist in implementing mitigations to prevent medication free flow incidents from occurring at a hospital. A medication free flow is when an IV medication that was infusing at a controlled rate through an infusion pump is no longer controlled or stopped and flows by gravity to the patient. With a high-risk medication, free flow can cause serious patient harm.
The hospital initially asked our team to create labels for all large volume infusion pumps to remind clinical users to 1) not open the pump door if the infusion line was still connected to the patient, and 2) return broken pumps to the medical engineering department. Our team created the pump stickers, while acknowledging that reminders are low on the hierarchy of effectiveness, and that the stickers would not be a fail-safe for preventing free flow incidents. Free flow incidents continued to occur, which is a serious safety issue, and as a result the hospital needed a new solution.
The hospital’s new proposed solution was to replace all large volume infusion pumps in the OR with syringe pumps. Our team was asked to assess the current state and identify painpoints with a switchover to syringe pumps. Observations and interviews in the OR and PACU were conducted and a current state map of high-risk medication delivery was created. We determined that the painpoints and risks associated with syringe pump implementation (namely, the risk of patient harm during frequent syringe changes) would be too great for syringe pumps in the OR to be a viable solution.
Our team proposed an alternative solution: use of anti-siphon valves (ASVs). Anti-siphon valves stop free flow when attached to the distal end of an IV tubing line, and would not pose the same risks to the patient as syringe pumps.
Further observations were conducted in the OR and PACU, followed by usability testing with OR, PACU, and CVICU scenarios, to observe possible difficulties clinicians would face using anti-siphon valves. Function testing was also conducted in collaboration with the medical engineering department, with anti-siphon valves attached to six IV lines running at low rates.
Based on observations and usability testing, painpoints associated with ASV implementation were identified. Our team worked with the medical engineering department and clinical team to devise a protocol for ASV use. Our team also created education materials and posters for clinical areas to help reduce identified issues.
This was followed by a pilot study that involved in-situ testing. ASVs were used in the OR for cardiac and vascular cases and traveled with patients to PACU and/or CVICU. Our team conducted observations and interviews with clinical staff to discover any issues arising with using ASVs for patient care. To address these issues, the ASV protocol, education, and education materials were updated.
Once the in-situ pilot study was deemed a success, the ASVs were rolled out in the OR, PACU, and CVICU for cardiac, vascular, living donors, and transplant patients. Free flow incidents have not been reported since.
Key Takeaways:
- To arrive at a viable solution, our team studied the current state, assessed proposed solutions, and then evaluated and tested the solution via usability testing and an in-situ pilot.
- A human factors perspective should be included at a solution discovery phase of strategy in addition to being included when creating tools for implementation. A human factors lens was essential for discovering and implementing the most viable mitigation strategy for medication free flow incidents.
- Conducting observations in the OR, PACU, and CVICU, and specifically following patients on their journey from the OR onwards, was key to understanding mitigation viability and identifying painpoints to address.
The hospital initially asked our team to create labels for all large volume infusion pumps to remind clinical users to 1) not open the pump door if the infusion line was still connected to the patient, and 2) return broken pumps to the medical engineering department. Our team created the pump stickers, while acknowledging that reminders are low on the hierarchy of effectiveness, and that the stickers would not be a fail-safe for preventing free flow incidents. Free flow incidents continued to occur, which is a serious safety issue, and as a result the hospital needed a new solution.
The hospital’s new proposed solution was to replace all large volume infusion pumps in the OR with syringe pumps. Our team was asked to assess the current state and identify painpoints with a switchover to syringe pumps. Observations and interviews in the OR and PACU were conducted and a current state map of high-risk medication delivery was created. We determined that the painpoints and risks associated with syringe pump implementation (namely, the risk of patient harm during frequent syringe changes) would be too great for syringe pumps in the OR to be a viable solution.
Our team proposed an alternative solution: use of anti-siphon valves (ASVs). Anti-siphon valves stop free flow when attached to the distal end of an IV tubing line, and would not pose the same risks to the patient as syringe pumps.
Further observations were conducted in the OR and PACU, followed by usability testing with OR, PACU, and CVICU scenarios, to observe possible difficulties clinicians would face using anti-siphon valves. Function testing was also conducted in collaboration with the medical engineering department, with anti-siphon valves attached to six IV lines running at low rates.
Based on observations and usability testing, painpoints associated with ASV implementation were identified. Our team worked with the medical engineering department and clinical team to devise a protocol for ASV use. Our team also created education materials and posters for clinical areas to help reduce identified issues.
This was followed by a pilot study that involved in-situ testing. ASVs were used in the OR for cardiac and vascular cases and traveled with patients to PACU and/or CVICU. Our team conducted observations and interviews with clinical staff to discover any issues arising with using ASVs for patient care. To address these issues, the ASV protocol, education, and education materials were updated.
Once the in-situ pilot study was deemed a success, the ASVs were rolled out in the OR, PACU, and CVICU for cardiac, vascular, living donors, and transplant patients. Free flow incidents have not been reported since.
Key Takeaways:
- To arrive at a viable solution, our team studied the current state, assessed proposed solutions, and then evaluated and tested the solution via usability testing and an in-situ pilot.
- A human factors perspective should be included at a solution discovery phase of strategy in addition to being included when creating tools for implementation. A human factors lens was essential for discovering and implementing the most viable mitigation strategy for medication free flow incidents.
- Conducting observations in the OR, PACU, and CVICU, and specifically following patients on their journey from the OR onwards, was key to understanding mitigation viability and identifying painpoints to address.
Authors
Event Type
Poster Presentation
TimeMonday, March 314:45pm - 6:15pm EDT
LocationFrontenac Foyer
Digital Health (DH)
Simulation and Education (SE)
Hospital Environments (HE)
Medical and Drug Delivery Devices (MDD)
Patient Safety and Research Initiatives (PS)