Addressing the Current Challenges in Infusion Medication Safety

This Infusion Nurses Society virtual symposium addresses error causation, including the impact of human factors, the hazards within medication preparation and administration, the risk of medication errors with infusion pumps, the effects of an adverse event upon the clinician, and the use of teamwork as a foundation for safety. The propensity of humans to err causes us to continually strive to find ways to minimize errors when infusing medications. Additionally, the COVID-19 pandemic has impacted the risk for errors due to staff shortages, concern about exposure to the virus, the emotional and physical stress of providing patient care, and the way patient care is delivered. This program offers new perspectives on preventing patient harm, supporting health care clinicians, and developing organizational safety systems.

  • Contains 3 Component(s), Includes Credits Includes a Live Web Event on 10/26/2022 at 1:00 PM (EDT)

    Introduction/Setting the Stage (15min) Effects of the Pandemic on Health Care Delivery and Impact on Patient Safety Oren Guttman, MD, MBA The Role of Human Factors and Resiliency Engineering in Advancing Patient Safety in Health Care Oren Guttman, MD, MBA

    Introduction/Setting the Stage (15min)

    Effects of the Pandemic on Health Care Delivery and Impact on Patient Safety

    The modern patient safety movement predated the massive digitization and technological transformation of health care that has occurred over the past 20 years—and therefore the modern patient safety movement by necessity began with a focus on social systems, human behavior, team behavior, and accountability. It is widely recognized that this approach has not achieved significant and enduring improvements in patient safety. Health care systems are experiencing additional headwinds that make social approaches to improving safety even more difficult: pandemic-induced staffing shortages, turnover, loss of those with expertise, new-to-practice staff less prepared for the clinical world, staff burnout and fatigue, and supply chain disruptions. In 2022, health care has become sociotechnical work, where the machines are no longer our tools; they are out partners. This massive digitization enables a systems-based approach to designing operating systems that both facilitate outstanding care and prevent harm.

    The Role of Human Factors and Resiliency Engineering in Advancing Patient Safety in Health Care

    In complex sociotechnical environments, operating systems largely determine the outcome. Clinical operating systems and safety management systems inform and define the safety behaviors of an organization, and therefore the culture of safety. It is important to design tools, technology, and processes that do not exceed the capability and capacity of those using the system. We need to hold our operating systems and safety management systems to the same high professional standards to which we hold ourselves. By incorporating human factors and resiliency engineering principles, organizations can identify areas of risk in the clinical operational systems that can impact patient safety. In this session, we will explore key strategies, operations, and tactics that will aid in reducing errors, that will avoid turning errors into failure, and that will keep any failure from spreading; we will also explore the role of nurses as an integral part of the team’s ability to rescue patients from harm.

    Learning Objectives:
    At the conclusion of this session, participants will be able to:
    • Describe the role of human factors and resiliency engineering in system safety
    • Identify recent advances and developments regarding human factors engineering and discuss their application to clinical practice.

    Oren Guttman, MD, MBA

    Oren Guttman, MD, MBA, serves as the enterprise vice president for high reliability and patient safety for Jefferson Health and is the Edward Asplundh Chief Quality and Patient Safety Officer at Jefferson Health-Abington division. He is a practicing associate professor of anesthesiology at Sidney Kimmel Medical College, and a member of the renowned Anesthesia Patient Safety Foundation. Dr. Guttman is a published author on patient safety and an expert in implementation science, with an international voice on patient safety and human factors. He is the chief architect of Jefferson Health’s Onpoint Safety Management System and consults on safety for health care and non-health care organizations such as Aramark, Medline, the American Heart Association (AHA), and others.

  • Contains 3 Component(s), Includes Credits Includes a Live Web Event on 10/26/2022 at 2:30 PM (EDT)

    According to INS Infusion Therapy Standards of Practice, the organization establishes the process for compounding and preparing parenteral solutions and medications. There is a higher rate of error with IV medications compared to other routes. Sources of error include dilution of IV push medications, adherence to Aseptic Non Touch Technique (ANTT®) practices to reduce the risk of infection, drug shortages, and workflow changes—as well as the many steps involved in preparation and administration processes. Institute for Safe Medication Practices (ISMP) and INS recommend methods to reduce risk such as ready-to-administer (RTA) for IV push medications. In this session, we will discuss methods and training used to promote safe infusion medication preparation and administration.

    According to INS Infusion Therapy Standards of Practice, the organization establishes the process for compounding and preparing parenteral solutions and medications. There is a higher rate of error with IV medications compared to other routes. Sources of error include dilution of IV push medications, adherence to Aseptic Non Touch Technique (ANTT®) practices to reduce the risk of infection, drug shortages, and workflow changes—as well as the many steps involved in preparation and administration processes. Institute for Safe Medication Practices (ISMP) and INS recommend methods to reduce risk such as ready-to-administer (RTA) for IV push medications. In this session, we will discuss methods and training used to promote safe infusion medication preparation and administration.

    Learning Objectives:

    At the conclusion of this session, participants will be able to:
    • List 3 common errors during preparation and administration of IV push medications
    • Describe how to prepare an IV push medication following ANTT guidelines
    • Discuss ways to enhance nurses’ role in proactively reducing IV push medication errors

    ​Maureen Burger MSN, RN, CPHQ, FACHE

    Maureen Burger is the chief nursing officer for Visante Consulting LLC, a medication management consulting firm. She has a long and varied career in positions of progressive responsibility, both in nursing and hospital administration, including as the vice president of quality, safety, risk, accreditation, and infection control for Indiana University Health. As a consultant now, she is thrilled to be able to focus her research, writing, and consulting on medication safety, especially when it involves IV push medications and drug diversion in health care. Maureen Burger obtained a master’s degree in critical care nursing from Case Western Reserve University, is certified in health care quality, and is recognized as a fellow by the American College of Healthcare Executives. She is the humble recipient of a Daisy Award, and a member of the American Organization for Nursing Leadership (AONL), the American Association of Critical Care Nurses (AACN), the Infusion Nurses Society (INS), the Association for Vascular Access (AVA), the American College of Healthcare Executives (ACHE), and the International Health Facility Diversion Association (IHFDA). She is a founding member of the National Coalition for IV Push Safety (www.ncivps.org), and is a frequent speaker and author on topics related to medication safety and drug diversion. When she is not advocating for patients and safety, Maureen Burger and her husband breed and race thoroughbred horses. She lives in Indianapolis, Indiana.

  • Contains 0 Component(s)

    Please complete the meeting evaluation to receive your continuing education certificate. Your feedback is important, as it helps INS better serve you and the membership. We need your input to continue to provide you with quality programs.

    Please complete the meeting evaluation to receive your continuing education certificate. Your feedback is important, as it helps INS better serve you and the membership. We need your input to continue to provide you with quality programs.

    Available at the end of the conference.

  • Contains 3 Component(s), Includes Credits Includes a Live Web Event on 10/27/2022 at 1:00 PM (EDT)

    Medication administration errors are among the most vexing and costly events in health care. A therapeutic infusion is intended to help the patient, but sadly patient harm through error can swiftly displace the intended therapeutic effect, which may result in disruption of therapeutic regimen, over- or underdosing leading to loss of intended therapeutic effect, debilitating injury, or even death. In 2020, the Institute for Safe Medication Practices (ISMP) published ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. Compiled and reviewed by many clinical experts, this resource outlines the components necessary for developing an organizational infrastructure that promotes safe patient care through the application of smart infusion pump technology. In this session, we will explore the interface between the infusion pump and the nurse (the interface between device and human) as well as the realm in which critical decisions are made and presumptive actions performed; and how successful or deleterious outcomes are initiated.

    Medication administration errors are among the most vexing and costly events in health care. A therapeutic infusion is intended to help the patient, but sadly patient harm through error can swiftly displace the intended therapeutic effect, which may result in disruption of therapeutic regimen, over- or underdosing leading to loss of intended therapeutic effect, debilitating injury, or even death. In 2020, the Institute for Safe Medication Practices (ISMP) published ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. Compiled and reviewed by many clinical experts, this resource outlines the components necessary for developing an organizational infrastructure that promotes safe patient care through the application of smart infusion pump technology. In this session, we will explore the interface between the infusion pump and the nurse (the interface between device and human) as well as the realm in which critical decisions are made and presumptive actions performed; and how successful or deleterious outcomes are initiated.

    Learning Objectives:
    At the conclusion of this session, participants will be able to:
    • Describe the role of smart infusion pumps in optimizing medication safety during medication infusions
    • Discuss the risks and benefits of using smart infusion pumps for medication administration
    • Explain how to improve the utilization of smart infusion pump technology in the healthcare setting

    Evan Frasure, PharmD, BCPS

    Evan S. Frasure III, PharmD, BCPS, is currently the director for controlled substance diversion prevention for Duke University Health System. He graduated from pharmacy school at Idaho State University in 2007 and completed a PGY1 residency at Carolinas Medical Center-NorthEast in Concord, North Carolina, where he stayed until he started his career at Duke in 2011. Dr. Frasure has held various roles during his time at Duke, including positions involving continuity of care, administration, and business services. He started in his current role in March 2017.  In this role, in addition to overseeing the diversion prevention efforts across the Duke University Health System, Dr. Frasure chairs the Duke University Hospital Smart Pump Quality Oversight Committee and the Department of Pharmacy Core Safety Committee, overseeing quality assurance initiatives and regulatory compliance. He is passionate about patient and medication safety.

  • Contains 3 Component(s), Includes Credits Includes a Live Web Event on 10/27/2022 at 2:15 PM (EDT)

    Medical errors occur frequently in health care with lasting impacts for both the consumers and the health care professionals involved. The COVID-19 pandemic has created a sequela of events that have compounded existing stressors in the workplace which contribute to a propensity for error. When an error does occur, clinicians are often poorly supported, leading to detrimental impacts on their well-being and their ability to recover and grow following the event. These impacts have implications for systems learning, patient experience, and safety. Evidence from more than 20 years of research provides insights into strategies that can be applied by health care leaders, managers, and colleagues to respond proactively in order to optimize recovery and to implement constructive change following errors. In this session, attendees will learn about how making an error can impact clinicians and the approaches that can mitigate clinician suffering and promote individual and collective recovery.

    Medical errors occur frequently in health care with lasting impacts for both the consumers and the health care professionals involved. The COVID-19 pandemic has created a sequela of events that have compounded existing stressors in the workplace which contribute to a propensity for error. When an error does occur, clinicians are often poorly supported, leading to detrimental impacts on their well-being and their ability to recover and grow following the event. These impacts have implications for systems learning, patient experience, and safety. Evidence from more than 20 years of research provides insights into strategies that can be applied by health care leaders, managers, and colleagues to respond proactively in order to optimize recovery and to implement constructive change following errors. In this session, attendees will learn about how making an error can impact clinicians and the approaches that can mitigate clinician suffering and promote individual and collective recovery.

    Learning Objectives:
    At the conclusion of this session, participants will be able to:
    • Describe the impacts and sequalae of making a medical error on clinicians and patient care
    • Discuss the strategies that support and follow-up following a medical error that contribute to constructive changes being made in practice
    • Explain how healthcare leaders can best support those involved in a medical error to enhance well-being and care

    Reema Harrison, PhD

    Reema Harrison, PhD, MSc, BSc (hons), a senior fellow of the Higher Education Academy, leads the Healthcare Engagement and Workplace Behaviour Research Stream, a team of health services researchers, at the Australian Institute of Health Innovation in Macquarie University. Dr. Harrison also holds adjunct appointments with UNSW School of Population Health and the Institute of Psychological Sciences at the University of Leeds in the United Kingdom. She is a mixed-methods researcher with expertise in using codesign and participatory approaches with diverse populations, and has a strong track record of translational health systems and services research, with demonstrated policy and practice impacts. As a result, Dr. Harrison is identified in the top 10% of patient safety experts internationally, and one of the top five in Australia. Dr. Harrison has published more than 100 peer-reviewed research articles, given more than 80 research presentations (including more than 30 keynote and invited), designed and delivered more than 10 undergraduate, postgraduate, or professional development courses, and supervised more than 30 higher degree research student projects. She is an associate editor for BMC Health Services Research and the Journal of Interprofessional Care.

  • Contains 3 Component(s), Includes Credits Includes a Live Web Event on 10/27/2022 at 3:30 PM (EDT)

    In this session learners will shift the patient safety mindset from learning from and responding to error to more deeply understanding how teamwork is the foundation of safety. As we put the patient at the center of our care, we recognize the interconnectedness of the complex system in which care is delivered—the importance of the team. We will expand the conversation on infusion safety and the traditional Safety 1.0 thinking to the concept of Safety 2.0—understanding why things go right. Participants will recognize the power of teams in complex adaptive systems, take away specific skills to enhance teamwork, and be re-energized to continue making a positive impact in the lives of patients.

    In this session learners will shift the patient safety mindset from learning from and responding to error to more deeply understanding how teamwork is the foundation of safety. As we put the patient at the center of our care, we recognize the interconnectedness of the complex system in which care is delivered—the importance of the team. We will expand the conversation on infusion safety and the traditional Safety 1.0 thinking to the concept of Safety 2.0—understanding why things go right. Participants will recognize the power of teams in complex adaptive systems, take away specific skills to enhance teamwork, and be re-energized to continue making a positive impact in the lives of patients.

    Learning Objectives:
    At the conclusion of this session, learners will be able to:
    • Describe the differences between Safety 1.0 and Safety 2.0 thinking
    • Discuss the importance of shifting the patient safety mindset to learning why things go right using a patient story
    • Explain specific strategies to enhance teamwork to support safety

    Kara Lyven, MBA, CPPS

    Kara Lyven, MBA, CPPS, is the executive director for patient safety at Duke University Hospital, where she provides oversight and operational leadership for the hospital’s patient safety program. Kara joined Duke in 2016 as a senior patient safety associate and previously served as the director of North Carolina Hospital Association’s (NCHA) Patient Safety Organization. She gained extensive experience as a patient safety and quality improvement specialist for 10 years at a 452-bed hospital in upstate New York and has served as a regulatory safety associate at Pfizer in New York City. Kara Lyven holds a bachelor’s degree in neuroscience and an MBA in pharmaceutical studies, and is a certified professional in patient safety (CPPS) and a TeamSTEPPS® master trainer. She is Green Belt certified and is a faculty member with the Institute of Health Improvement (IHI).