Most intravenous (IV) “high-alert” drugs are titrated, meaning the dose changes are made after the infusion starts — and that creates multiple opportunities for programming errors.

On top of that, there aren’t any protocols in place to monitor titrations and most infusion pumps aren’t designed to spot titration errors.

An analysis presented this week at the Infusion Nurses Society annual meeting evaluated infusion pump data from 20,542 of Baxter’s Sigma Spectrum pumps at 45 hospitals in the U.S. Six months of data per site was studied, which spanned the period from October 2014 to July 2015.
All of the infusions involved high-alert IV medications administered to adult patients in critical care, the operating room, or for anesthesia. The researchers found that 90 percent of the programming events were titrations.

The drug that was titrated the most was norepinephrine, which is used to treat low blood pressure. It was titrated on average about 15 times during an active infusion, which allowed for 15 opportunities for programming errors.

The other drugs with the most titrations per infusion were insulin, phenylephrine, propofol, and epinephrine, which had 11, 10, nine and eight titrations respectively.

Before this study, there were no published data evaluating the frequency of titration programming and the potential for errors. The researchers believe that this data will help the industry develop more effective infusion practices for better patient safety.

In 2012, infusion pump medication errors were number three on ECRI’s Top 10 Technology Hazards list, and in 2013 and 2014 it jumped up to number two on the list. The industry has been working hard to try to curb this.

One solution is Baxter’s Sigma Spectrum Infusion System, which uses drug libraries to alert clinicians if there is a potential error before an infusion begins. It’s the only infusion pump that has a built-in titration error prevention feature.

A multi-hospital study published online in BMJ Quality & Safety in March found that hospitals need to do more than implement “smart” pumps to reduce medication errors. The researchers found that more than half of infusions of IV medications contained errors, and most of them were caused by deviations in hospital policy.

However, based on comparisons with previous studies, the medication-related errors were much lower. That shows that implementing smart pump technology has improved infusion safety, but unfortunately not enough.

The researchers recommended that hospitals should focus on reviewing existing practices and policies that are associated with medication administration and also working on smart pump interoperability.

“This research illustrates that while we have come a long way since our initial conversations about infusion safety at the 2010 AAMI/FDA Infusion Device Summit, there is still more work to do,” Marilyn Neder Flack, senior vice president of patient safety initiatives at AAMI and executive director of the AAMI Foundation, said in a statement.

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