1. Laura Kirk, MD Benjamin Reynolds, MD Jason Papazian, MD
QI Project
Laura Kirk, MD
Benjamin Reynolds, MD
Jason Papazian, MD

2. SENTINEL EVENT
Alaris pump tubing wet down with IV narcotic and placed directly into IV line with clamps open outside of the pump casing, allowing entire 50 cc vial of narcotic to be given to patient

3. PREVALENCE Initial sentinel event brought issue to forefront
Multiple anecdotal reports
MEDMARX Medication Error Database reports errors of omission and improper dose quantity were most commonly reported between January 1, 1999 and December 31, 2001 resulting in death in 19 cases
Many events likely unreported

4. Stakeholders Patients In room anesthesia provider Supervising provider
Nursing staff
Surgeons

5. Process Map Medication ordered and obtained from pharmacy
Tubing opened from anesthesia cart
Close at least 1 distal roller clamp
Spike medication bag
Hang med bag and place tubing in pump
Reclose distal clamp while keeping end sterile
Open previously closed clamp, prime to end of tubing
Squeeze air chamber
Turn system on and program infusion
Recheck dosing/medication settings
Open clamps
Connect to appropriate patient access point
START INFUSION

6. Fishbone Diagram Patient Factors Staff Factors Task Factors
Communication
Team
HD Unstable
Access
Rushing
Pressure
Fatigue
Lack of training
Inexperience
No training
Roller clamp stiff
No protocol/not followed
Not intuitive
No published manual
No formal training
Attending not present
Anesthesia techs not present
Inadvertent overdose
Difficult to read
Tubing disconnects
Incompatible components
Not intuitive
Level of experience
Rushed environment
Help not immediately present
Risky medications (e.g opioids, epi) not marked
No training on pumps
Education
Equipment
Environmental
Organizational

7. Smart Aim Statement
All first year anesthesia residents will have instructional training by anesthesia technicians on appropriately wetting down Alaris pump tubing during orientation week of their CA-1 year, and proper technique will be demonstrated by wetting down tubing outside of the OR environment. Anesthesia residents will then be “champions” to the rest of the hospital on instruction and demonstration of safe Alaris pump tubing set-up and use.

8. SMART AIM IN ACTION: PDSA MODEL
PLAN: Large scale, longitudinal hospital wide, anesthesia driven
Objective: minimize large volume drug administration errors
Prediction: early and complete education leads to minimized error
Requirements: education, resident dispersal to hospital wide-units

9. SMART AIM IN ACTION: PDSA MODEL
DO: SMART AIM outlined education used in a “1-educates-5” model
Potential Negatives: anesthesia deemed “overbearing”
Data collection: surveys to ICUs where residents are working, QI system review
Initial data on incidence of this type of event over the last 4 years at our hospital will be collected

10. SMART AIM IN ACTION: PDSA MODEL
STUDY: On a quarterly basis all units will have to develop a detailed report of all Alaris pump related drug errors to be categorized and analyzed
Will necessitate correcting for non—overdose related errors
Some errors may involve overdose but PUMP error and not tubing error
This could become a sub-analysis and lead to another QI project…

11. SMART AIM IN ACTION: PDSA MODEL
ACT: Protocolization and education  Increased patient safety
Anesthesia is not a normal face in many hospital units
Nurses or other providers may be resistant or feel “their way” is better
Respectful concern for these issues is important when getting everyone involved