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Bringing Smart Pump Technology to RQHR

30-Nov-2015

Background:

The course of Allison Wells’ life changed the morning of May 29, 2014. That was the day her then three-year-old son, Logan, nearly died. Logan, who has a rare kidney disorder, experienced a string of medical errors but it was one near fatal error that changed everything.

While being prepared for a gastroscopy at Royal University Hospital in Saskatoon, Logan was connected to an intravenous (IV) bag containing more than five times the appropriate concentration of potassium chloride.

“All of a sudden, Logan is screaming, writhing and trying to rip his IV out,” said Allison, who works as a Regina Qu’Appelle Health Region (RQHR) pharmacist. “I looked behind me and saw the bag of potassium and knew immediately it was too concentrated. I have a screaming child, I’m wiping puke off of myself and him, and am telling everyone that this IV can’t be run.”

Failing to capture anyone’s attention, Allison locked her son’s IV, which stopped the toxic dose from flowing into his body.

Bringing smart pump technology to RQHR

The implementation of provincial “smart” infusion pump technology and of a standardizedparenteral formulary is vitally important to Allison.

Infusion pumps are electronic devices used to deliver fluids, medications and nutrition to patients. Smart pumps differ from typical infusion pumps in that they are pre-programmed with a drug library containing drug dosing information. Should a clinician attempt to program the pump with the wrong dose, the smart pump has built-in safety features that significantly reduce the chance of errors reaching the patient.

A parenteral formulary is a drug resource/dictionary which helps guide health care providers on how to administer, monitor and watch for specific drug interactions/side effects when medications are given intravenously.

Allison represents RQHR on the implementation team overseeing this project. Her role is to work with pharmacists, nurses, and physicians across the province to standardize the library and help define concentrations and develop safe drug limits. This will provide a level of consistency within the province never before seen. The smart pump program is expected to be rolled out in RQHR in early 2016. The rest of the province will follow, with all health regions adopting the technology and equipment by the end of 2016.

If Logan’s IV had been connected to a smart pump the day of his surgery, the near fatal error would not have reached him and he, his family and his health care team would not continue to re-live those events to this day.