Overriding Technology May Impact Patient Safety

Recent research by the Pennsylvania Patient Safety Authority has concluded that overrides of medical technology may impact the safety of patients.

The PA Authority analyzed 583 events reported during the period January 2013 to December 2014. Key findings from this analysis:

  • The majority (77%) were related to automated dispensing cabinets.
  • The most common classes of medications involved antibiotics (12.0%), opioids (12.0%), anticoagulants (7.4%), and high alert medications (26.4%).

The chart below shows the technologies overridden:

Technologies Overridden
Technologies Overridden
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Medical technology may provide the strongest fix to patient safety concerns by implementing forcing functions. One example of this forcing function has been implemented by Veterans Affairs.

Bryanne Patail, (formerly) biomedical engineer at the U.S. Department of Veterans Affairs, National Center for Patient Safety, discussed patient-controlled analgesia (PCA) pumps and what the Veterans Health Administration has done to reduce errors and improve patient safety:

One action that VHA has taken to address this high error incident rate is to use a PCA pump that has an integrated end tidal CO2 monitor or capnograph. A capnograph measures in real-time the adequacy of ventilation. Using this technology could prevent more than 60 percent of adverse events related to PCA pumps.

Use of PCA pumps is a process, and improving that process is an area that involves many stakeholders. In looking at fixes, they can be categorized as strong, intermediate or weak fixes. The strongest fix for PCA pumps is a forcing function, such as an integrated end tidal CO2 monitor that will pause the pump if a possible over infusion occurred. So, healthcare providers should first look at these strong fixes. There they will see the most impact on reducing errors and improving patient safety.

An example of technology being overridden as described in the PA Authority’s research:

Order entered for oxyCODONE ER [extended release] 40 mg po TID [by mouth three times a day] as well as morphine ER 100 mg po TID. The pharmacist noted that this was unusual [concurrent prescriptions for two extended-release opioids] and put the order on pending status until clarified. The nurse told the pharmacist that since the patient was having pain, she had overridden and administered the oxyCODONE ER without pharmacy verification at a time when the pharmacy was open. Upon clarifying with the patient’s pharmacy, the pharmacists determined that the patient was actually on oxyCODONE immediate release 40 mg po TID prn [as needed for] pain.

To read the research and PA Authority’s risk reduction strategies, please click here.

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