Location
Virtual
Start Date
7-3-2025 8:00 AM
End Date
7-3-2025 3:15 PM
Description
Purposes/Aims: The purpose of this program evaluation is to assess the effectiveness of an infusion pump-EHR interface system, Alaris Interoperability, on the incidence of medication errors, consistency of staff utilization, accuracy of documentation, staff satisfaction and clinical outcomes in an inland northwest intensive care unit (ICU).
Rationale/Background: Medication errors are preventable events that account for nearly half of all medical injuries, with an annual global estimated cost of $42 billion USD (WHO, 2023; WHO, n.d.).
In spring 2023, a 197-bed community hospital implemented Alaris Interoperability, a program intended to standardize intravenous medication administration. This program created a virtual interface between infusion pumps and the electronic health record (EHR), allowing for automatic calculation of drip rates, volumes & dosages. This new workflow sought to reduce medication errors and improve documentation accuracy by removing manual input by the RN. With its high patient acuity and increased utilization of infusion pumps, the ICU was selected to evaluate system usability and patient outcomes. Since implementation, there have been technical challenges, difficulties in staff training, and varying compliance regarding this change in practice. Many staff members are dissatisfied with the education they received and the functionality of the program itself, leading to inconsistent utilization amongst employees. If this software is bypassed or used incorrectly, this may lead to errors in medication administration, documentation inaccuracy and potential patient harm.
Approach/Methods: The CDC program evaluation framework guided this project. Incorporating the framework’s six steps, medication error incidence before & after implementation was measured via internal data reports; quarterly data was reviewed for 18 months pre- and post-implementation in the intensive care setting to measure program impact. Internal reports measuring usability rates documented compliance amongst ICU RN’s. Chart reviews were completed by an internal third party to measure the rate of intravenous infusion verification through the EHR. Average length of stay before & after implementation was measured using internal data reports. The project lead developed an evidence-based Likert-type survey which was distributed to ICU staff to measure attitudes regarding the program; these questionnaires assessed Alaris Interoperability value, ease of use, effectiveness in decreasing medication errors and effect on workload/workflow. Open-ended questions were used to gather qualitative responses from staff.
Assessment of Findings/Outcomes: Average medication error rate (per 10,000 billed doses) pre intervention was 0.75 (σ 1.16), while the average medication error rate post-intervention was 0.89 (σ 1.10). There were three documented infusion-related medication errors since Oct 2023; Alaris Interoperability was over-rode in all three instances. Staff compliance increased from 80% to 92% between June 2023 and Nov 2024. 90 charts were audited to assess documentation accuracy; only 44% of RNs completed IV drip verification per policy. Average LOS pre-intervention was 2.93 days (σ 0.24), while average LOS post-intervention was 3.07 days (σ 0.30). Regarding staff attitudes, 18 survey responses were received comprising a 46% response rate. 72% of respondents agree/strongly agree that Alaris Interoperability eases charting, while 17% agree/strongly agree that they need more training on Alaris Interoperability. Staff reported improved charting efficiency, but cite disrupted workflow, challenges with drip verification & inconsistent use amongst nurses. Confounding variables may have affected LOS, including the implementation of in-house dialysis. Contextual med error data is unavailable prior to Oct 2023 due to a change in reporting systems, thus, the true impact of Alaris Interoperability on med error rate is unknown.
Conclusion: Further investigation is necessary; software has only been in use for 18 months; thus, its impact may not be fully realized. Verification compliance should be augmented to improve documentation accuracy & team-based culture is necessary for successful use of the technology. Further education may be indicated for staff regarding importance of drip verification/policy and other units should be investigated to understand the broader impact
Recommended Citation
Robins, Julia, "Evaluating Use and Outcomes of an Infusion Pump-EHR Interface System" (2025). Providence Nursing Research Conference 2023 – Present. 8.
https://digitalcommons.providence.org/prov_rn_conf_annual/2025/posters/8
Specialty/Research Institute
Nursing
Included in
Evaluating Use and Outcomes of an Infusion Pump-EHR Interface System
Virtual
Purposes/Aims: The purpose of this program evaluation is to assess the effectiveness of an infusion pump-EHR interface system, Alaris Interoperability, on the incidence of medication errors, consistency of staff utilization, accuracy of documentation, staff satisfaction and clinical outcomes in an inland northwest intensive care unit (ICU).
Rationale/Background: Medication errors are preventable events that account for nearly half of all medical injuries, with an annual global estimated cost of $42 billion USD (WHO, 2023; WHO, n.d.).
In spring 2023, a 197-bed community hospital implemented Alaris Interoperability, a program intended to standardize intravenous medication administration. This program created a virtual interface between infusion pumps and the electronic health record (EHR), allowing for automatic calculation of drip rates, volumes & dosages. This new workflow sought to reduce medication errors and improve documentation accuracy by removing manual input by the RN. With its high patient acuity and increased utilization of infusion pumps, the ICU was selected to evaluate system usability and patient outcomes. Since implementation, there have been technical challenges, difficulties in staff training, and varying compliance regarding this change in practice. Many staff members are dissatisfied with the education they received and the functionality of the program itself, leading to inconsistent utilization amongst employees. If this software is bypassed or used incorrectly, this may lead to errors in medication administration, documentation inaccuracy and potential patient harm.
Approach/Methods: The CDC program evaluation framework guided this project. Incorporating the framework’s six steps, medication error incidence before & after implementation was measured via internal data reports; quarterly data was reviewed for 18 months pre- and post-implementation in the intensive care setting to measure program impact. Internal reports measuring usability rates documented compliance amongst ICU RN’s. Chart reviews were completed by an internal third party to measure the rate of intravenous infusion verification through the EHR. Average length of stay before & after implementation was measured using internal data reports. The project lead developed an evidence-based Likert-type survey which was distributed to ICU staff to measure attitudes regarding the program; these questionnaires assessed Alaris Interoperability value, ease of use, effectiveness in decreasing medication errors and effect on workload/workflow. Open-ended questions were used to gather qualitative responses from staff.
Assessment of Findings/Outcomes: Average medication error rate (per 10,000 billed doses) pre intervention was 0.75 (σ 1.16), while the average medication error rate post-intervention was 0.89 (σ 1.10). There were three documented infusion-related medication errors since Oct 2023; Alaris Interoperability was over-rode in all three instances. Staff compliance increased from 80% to 92% between June 2023 and Nov 2024. 90 charts were audited to assess documentation accuracy; only 44% of RNs completed IV drip verification per policy. Average LOS pre-intervention was 2.93 days (σ 0.24), while average LOS post-intervention was 3.07 days (σ 0.30). Regarding staff attitudes, 18 survey responses were received comprising a 46% response rate. 72% of respondents agree/strongly agree that Alaris Interoperability eases charting, while 17% agree/strongly agree that they need more training on Alaris Interoperability. Staff reported improved charting efficiency, but cite disrupted workflow, challenges with drip verification & inconsistent use amongst nurses. Confounding variables may have affected LOS, including the implementation of in-house dialysis. Contextual med error data is unavailable prior to Oct 2023 due to a change in reporting systems, thus, the true impact of Alaris Interoperability on med error rate is unknown.
Conclusion: Further investigation is necessary; software has only been in use for 18 months; thus, its impact may not be fully realized. Verification compliance should be augmented to improve documentation accuracy & team-based culture is necessary for successful use of the technology. Further education may be indicated for staff regarding importance of drip verification/policy and other units should be investigated to understand the broader impact
Comments
References:
VanHorn, T., Harris, J., Mayes, S., Infanti, L. M., & Kennedy, A. (2024). Evaluation of the Effect of Smart Pump Interoperability on Infusion Errors in the Pediatric Hospital Setting. The journal of pediatric pharmacology and therapeutics: JPPT: the official journal of PPAG, 29(3), 323–330. https://doi.org/10.5863/1551-6776-29.3.323
World Health Organization (WHO). (n.d.). Medication without harm. https://www.who.int/initiatives/medication-without-harm
World Health Organization: WHO. (2023, September 11). Patient safety. https://www.who.int/news-room/fact-sheets/detail/patient-safety