Kathy Francis, RN and InformMed pac2 technology inventor, says, "Wrong dose errors account for 41% of fatal medication errors, yet 10-20% of all doses are calculated at the point of care. By helping nurses to accurately calculate dose volumes, recognize unsafe doses, and recall clinically important drug information, the pac2 helps protect nurses and patients from tragic results."
The analysis showed that an 88% reduction in total potential risk of medication error could be realized when the pac2 was used in the Children's Hospital Pediatric Intensive Care Unit (PICU). According to Dr. Adalberto Torres, Jr., Medical Director for the Children's Hospital PICU, the study's reduced error rates offer valuable insight into the potential of the InformMed pac2 system in an emergent care setting. The Children's Hospital cares for more children in Illinois than any hospital outside of Chicago, and was recently recognized as having the #1 Neonatal Intensive Care Unit in the world. "When it comes to treating the youngest patients, there's absolutely no room for mistakes because infants and children are the least able to tolerate even small dose errors," Dr. Torres explains. "Therefore, the need for nurse review of all medication doses at the bedside remains critical. The pac2 improves on traditional methods used by nurses, and we are even more excited that our expectations have been exceeded in clinical practice, where we have seen reported dose errors drop by 95%."
Key FMEA Findings Presented at IHI Forum
Clinicians from Children's Hospital of Illinois along with Six Sigma Black Belts analyzed the impact of the pac2 system by breaking down the emergent IV medication administration process into five steps. They identified failure points and assigned Risk Priority Numbers (RPNs) based on the potential impact of each failure.
Dr. Torres presented the following highlights from the FMEA poster at the IHI Forum:
-- Total potential risk for patients, measured by the Risk Priority Numbers (RPNs), fell 88% overall when failure points were assessed for the five steps using the pac2, .
-- RPNs dropped for each step in the process, ranging from 73-99% reduction in potential failures.
Earlier research conducted by Dr. Torres showed similarly dramatic results:
-- The pac2 not only improved the accuracy of medication dose volumes measured by nurses during simulated scenarios, but significantly reduced the amount of time needed to perform accurate dosing calculations.
-- The pac2 allowed nurses to more frequently recognize unsafe doses and recall essential drug information. These performance improvements were observed consistently across all hospital setting subgroups despite differences in experience levels.
-- Improvements were observed for the pediatric and critical care nurses, and most of the nurses (87%) stated that they would prefer the pac2 over their current methods in actual practice.
About InformMed
InformMed is a medication safety company focused on developing, patenting and commercializing innovative product and service-based solutions for the growing medication error solution market. InformMed's patented flagship product, pac2(TM), is a performance-support system designed to help nurses prevent wrong dose errors at the point of care, a major healthcare problem. For more information, visit: www.informmed.com.
About OSF Saint Francis Medical Center
OSF Saint Francis Medical Center is a 616-bed academic and regional medical center with 5,700 employees and more than 800 physicians on staff. It is a level 1 trauma center with the more active medical transport system (Life Flight) in Illinois. It is home to the Illinois Neurological Center and the OSF Saint Francis Heart Hospital.
About Children's Hospital of Illinois
Located within OSF Saint Francis, Children's Hospital of Illinois is downstate Illinois' most comprehensive center for pediatric services. It is a level 3 perinatal center with neonatal and pediatric intensive care units complimenting two general pediatric units. It has more than 80 pediatric specialists on staff and draws patients from 60 Illinois counties.
