2009 Pre- and Post-pac2 Implementation Study
National Patient Safety Foundation Annual Congress, Poster Session, 2009
Reducing Pediatric Medication Dosing Errors Using Computer-Based Algorithm Calculators
Julie Kasap, PharmD. Children’s Hospital of Illinois. OSF Saint Francis Medical Center Peoria, IL
In the first seven months of clinical use in pediatric intensive care unit and the pediatric intermediate care areas, Children’s Hospital investigators saw reported dose errors drop by 95%. During the study phase, which included more than 10,000 doses verified by nurses using the InformMed system, only one dose error was reported, as compared to 21 dose errors reported in the seven months prior.
Risk Reduction during Emergent IV Medication Administration: A Failure Modes and Effects Analysis
Institute for Healthcare Improvement, Poster Session, 2008
OSF Saint Francis Medical Center Children’s Hospital of Illinois, Peoria, IL
Adalberto Torres, M.D., Medical Director of the Pediatric Intensive Care Unit
Carolyn Henricks, R.N., Congenital Heart Center Database Coordinator Children’s Hospital of Illinois
As an academic medical center and magnet hospital, Children’s Hospital of Illinois recognized the risk of dose errors and now they count on the InformMed point-of-care safety net for their nurses and patients.
Clinicians in the Pediatric Intensive Care Unit and Six Sigma Black Belt investigators from The Children’s
Hospital of Illinois conducted a FMEA of the emergent IV medication administration process. The administration process was broken into five steps, failure points were identified and risk scores were assigned based on the potential impact of each failure. When failure points were then assessed for the five steps using the InformMed system, total potential risk numbers fell 88% representing a dramatic potential reduction in risk for patients.
Pharmaceutical Algorithm Computerized Calculator (pac2) Efficacious in Reducing Medication Errors during Simulation
University of Illinois College of Medicine, Peoria, IL.
Society of Critical Care Medicine Critical Care Congress 2008, Poster Presentation # 546
Girish G Deshpande, David L Buchanan, Adalberto Torres, Jr, University of Illinois College of Medicine, Peoria, IL; Patricia L Ruppel, Innovative Analytics, Kalamazoo, MI
The University of Illinois College of Medicine hypothesized that the handheld system would significantly improve the accuracy of medication dose volumes calculated and measured by nurses during clinical scenarios using a pediatric patient simulator.
Thirty-three nurses were enrolled into a within-subject controlled study to evaluate the incidence of medication calculation and dose volume errors. The nurses were randomly divided into 2 groups and each group participated in a simulated emergency clinical scenario (A = status epilepticus or B= anaphylaxis) with the use of standard calculators, emergency drug info cards, etc. and then participated in the other scenario using the InformMed system.
The InformMed system significantly improved the accuracy of medication dose volumes measured by nurses during simulated scenarios while significantly reducing the amount of time used to calculate medication dose volumes. Enhancing the nurse’s capacity to recognize unsafe medication doses prescribed inadvertently and recall essential medication information would also improve patient safety.
Usability Study yields 94% Reduction in Errors
Nurses Improve Calculations for Medication Dosing: Errors add up to the need for innovative solutions. Joint Commission Benchmark, Vol. 7, Issue 6, (Nov/Dec 2005)
Rutgers University School of Nursing
The InformMed system has been tested for efficacy in a non-clinical setting by Rutgers University School of Nursing.
The Rutgers study included 151 nurse participants. The nurses were tested on clinical scenarios which required dose calculation. Then, after five minutes of training, the nurses were re-tested using the InformMed system for calculation and dose verification support. With the InformMed system, dosing error rates decrease from 45 percent to 3 percent.