First, Do No Harm: Making Infusion Pumps Safer
Jody Lannen Brady
fficially, artist Andy Warhol died from cardiac initiative, is “to support the benefits infusion pumps can arrhythmia, a complication after “routine” gall- provide while reducing associated risks.” While manu- Obladder surgery in 1987. But his family won facturers have already introduced some design changes millions in a lawsuit against the New York City hospital to cut down on errors, all parties agree that more needs where he underwent his surgery by successfully arguing to be done. that the arrhythmia was a result of water intoxication An estimated 90 percent of hospital patients receive an caused by faulty administration of an infusion pump. infusion as part of their treatment.1 The pumps deliver Other infusion errors and pump failures—from opioid nutrients and medications like pain killers, antibiotics, overdoses, to battery malfunctions, to software errors, to and chemotherapy drugs that can mean the difference dosage miscalculations—may not make the headlines, between life and death. But the powerful medications can but they seriously threaten the health and well-being of cause serious harm, even death, if improperly delivered. patients. The particularly bad news for patients is that Healthcare providers, clinical engineers, and manu- these are far from being isolated cases. After receiving facturers have long been aware of a disturbing trend in 56,000 reports of infusion pump incidents—including errors and faulty performance associated with infusion 710 deaths—and issuing 87 infusion pump recalls be- pumps. Seven years ago, a Massachusetts General Hos- tween 2005 and 2009, the U.S. Food and Drug Admin- pital infusion pump task force reported that “compelling istration (FDA) has initiated a sweeping program aimed incidents and near-misses motivated the formation of at preventing infusion pump problems and improving our team, and led to the devotion of significant energy patient safety. to preventing IV drug administration errors.”2 Twelve The goal, according to an FDA white paper on the years before that, a Harvard Medical Practice Study re- ported that infusion errors and drug complications were Jody Lannen Brady is a freelance writer the most common type of preventable adverse events based in Philadelphia, PA. E-mail: jody. reported in hospitals.3 [email protected] Until recently, end users—nurses and doctors backed by pharmacists—bore the burden of performing complex mathematical conversions of dose rate units into fluid- flow units. And if a busy floor nurse programming an IV
372 September/October 2010 COVER STORY Jody Lannen Brady First, Do No Harm:
device at a patient’s bedside missed a decimal point or that manufacturers redesign intelligent pumps to focus accidentally double-pressed a key, the resulting dosage on user-defined, rather than vendor-defined, features. error could be fatal. “They recommended such functionality as teaching “Smart pumps,” complete with onboard drug libraries prompts embedded in pump controls; standardized field and dose-monitoring capabilities, were seen by many as names and dose expressions that match infusion order- the best hope to address the problem. By 2005, almost writing conventions; a pump programming sequence that one-third of hospitals had begun using smart pumps; matches the medication order sequence; and the ability four years later, more than half of the nation’s hospitals to back out of a wrong action,” explains Bona Benjamin, reported adopting the technology.4 But, as current FDA director of medication-use quality improvement at the statistics point out, nascent “smart pump” technology ASHP. “It’s puzzling that such features are not available hasn’t proven a panacea for infusion pump problems. now—or why users do not perceive them to be available. “You can still hang the wrong bag on a device and the Apparently many infusion devices are not as ‘usable’ as machine would never know,” says Marla Husch, a patient they need to be. Why not?” safety expert and project manager at Central Dupage So what’s the answer to this complicated problem? Hospital in Illinois. Previously, Husch was the project Well, not surprisingly, it’s complicated. manager responsible for implementing the conversion to smart pumps at Northwestern Memorial Hospital. What Went Wrong? “Infusion pumps that perform as stand-alone devices— For starters, experts believe that infusion pump problems no matter how ‘smart’ they are— simply leave too many are compounded by inaccurate reporting of root causes. gaps,” Husch explains. “We do not have a valid analysis of the 56,000 reports A 2005 Northwestern Memorial study led by Husch of problems with infusion pumps,” says Nat Sims, MD, reported that more than two-thirds of the infusions ob- a physician advisor to Massachusetts General Hospital’s served by investigators had one or more errors associated Biomedical Engineering Department. Raw data submit- with their administration. Only one of the 389 errors ted by hospitals, manufacturers and others has proven could have been prevented by smart pump technology.5 “difficult to analyze—even by FDA analysts—to catego- At its July 2008 Safety Summit, the American Society rize primary and secondary causes,” Sims explains. of Health-System Pharmacists (ASHP) recommended FDA experts agree with Sims that discerning the cause
Biomedical Instrumentation & Technology 373 COVER STORY First, Do No Harm: Making Infusion Pumps Safer
We are only at the ment that is rife with distractions and simultaneous de- “beginning of what will be a lengthy process mands on the caregiver for multiple interactions with the of focusing on infusion pumps and on patient surrounding technology,” says Scales. And with increas- safety when patients are receiving IV infusions. ingly complex technology that requires more interaction Since infusion pumps are used in so many on the part of a clinician, errors become more likely. settings and in almost every hospital bed, many “We well know that no one wants to make errors, but changes will no doubt be forthcoming the environment we place our caregivers in frequently in the next few months and years.” predisposes them to become distracted, take shortcuts, or utilize work-arounds that lead to error-prone behavior.” —Nat Sims, MD, Many of these errors are flagged by an alert message, Massachusetts General Hospital but that doesn’t necessarily mean that the problem will be fixed. “During high stress, these messages are sometimes cleared without correcting the error,” says Scales. “Post- event analysis and user interviews frequently reveal that of pump failures and use errors is the first step to improv- users were completely unaware of having passed by the ing the safety of the devices. At a public meeting con- alert.” vened by the agency in May, Division of Electrical and Clinicians override some 90 percent of alerts, accord- Software Engineering Director Al Taylor explained that ing to Husch. Some of the alerts get ignored because cli- “many failure investigations reported by pump manufac- nicians are overtaxed, but others just “don’t make sense,” turers have misidentified the root cause of adverse events she says. In some dosage situations, alerts are automatic. as ‘use error’ or ‘random component failure.’” “They know that they’re going to get an alert every time FDA-run investigations have reached a different in that situation and that they’re going to override it ev- conclusion. “Many adverse events are caused by design ery time, so they become completely desensitized to all deficiencies that were foreseeable and preventable. Pump alerts.” deficiencies place an undue burden on users, caregivers, “When a system is designed in a way where there is and support staff, adding to an already stressful environ- a potential for errors, there will be,” says Tony Easty, ment,” said Taylor. senior scientist with the Centre for Global eHealth In- Pat Baird, a principal project engineer at Baxter Inter- novation in Toronto. “Training someone not to make national Inc. and co-chair of the AAMI Infusion Device mistakes isn’t effective. You can’t do it. We’re humans, Committee, says infusion pumps shouldn’t be looked at not machines. We’re not programmed to do the right in isolation. “The industry must look at infusion systems thing every time.” holistically, as part of this ecosystem of patient care, to In a recent study looking at the impact of traditional effectively tackle the potential safety issues we all face,” and smart pump infusion technology on medication Baird says. (Read more of Baird’s comments in the Final administration,6 Easty’s group observed a trend: Problems Word on page 440.) most often occurred when multiple drugs and therapies At the Duke University Health System, patient safety were being administered. When nurses were asked to specialist Glenn Scales and his colleagues have seen “piggyback” a drug, they repeatedly made errors. Easty infusion pump incidents that range from inadequately has been talking to manufacturers about the problem, validated software errors, to defects in the manufacturing and a follow-up study has been planned to focus on the of IV administration sets due to environmental issues in issue of multiple lines. the manufacturing facility, to improper manufacturing of “The theory is that greater complexity causes greater the devices themselves. “More common problems,” says error,” Easty says. “Not much work has been done in the Scales, include entering dose values in the ml/hr field, area of multiple infusions, so none of our current tech- entering incorrect numeric values in the correct field, nologies really address this issue.” transposing digits when entering values, and substituting As infusion pump use rises with an aging population, decimal points for zeros when entering values because these issues will only multiply, says Frank Overdyk, they are next to each other on the keypad. MSEE, MD, a professor of anesthesiology at the Medi- “Our clinical staff work in a very demanding environ- cal University of South Carolina. In Overdyk’s research,
374 September/October 2010 COVER STORY Jody Lannen Brady
Colleague pump recall may have garnered more atten- tion than other recalls, it’s just one of 87 recalls initiated by the agency in the past five years. In addition to the strain on operations during the time it takes a vendor to address such a problem, responding to recalls places a considerable “burden on hospitals to do a lot of the logistics work themselves,” reported Fraai. In an open letter to patient and healthcare profes- sional organizations this spring, Anthony Watson of the FDA Office of Device Evaluation wrote: “Problems with infusion pumps encompass multiple manufacturers and models. They include poor design, structural problems, and software defects. Although the overall benefits of using infusion pumps still outweigh the risks, this is an unacceptable situation.” Since that time, the FDA has set up an infusion pump website, drafted guidance for premarket reviews,7 convened a stakeholder teleconference, hosted a public workshop and planned an October summit, co-hosted by the Association for the Advancement of Medical In- strumentation. (See box on page 376.) The agency has demonstrated a “commitment to fixing this problem,” according to ASHP’s Benjamin. Here, a smart pump—the Harvard Clinical Technology “Harvard 2” pump, first sold in 1997—”questions” the user about what appears to be an unsafe dose “We are only at the beginning of what will be a lengthy of medication. Credit: MGH Photography/Joseph Ferraro process of focusing on infusion pumps and on patient safety when patients are receiving IV infusions,” says he sees an alarming rate of opioid infusion overdoses on Sims. “Since infusion pumps are used in so many settings general-care floors. “Usually, it involves a knowledge and in almost every hospital bed, many changes will no deficit about patient-controlled analgesia (PCA) devices doubt be forthcoming in the next few months and years.” on the part of the family and the nurses and providers,” Sims and his colleagues at MGH have long been says Overdyk. “The lockout and hourly limit constraints leaders in patient safety initiatives, including one on are interpreted as a foolproof safety mechanism. They infusion pump safety. Changes have included preparing are obviously not.” standardized syringes and drug bags of IV medications in Working to keep existing pumps performing safely the hospital pharmacy or an outsourced compounder to doesn’t come cheaply. Michael Fraai, director of Bio- eliminate “ad hoc compounding at the bedside.” MGH medical Engineering at Brigham and Women’s Hospital also has computerized provider order entry (CPOE) in Boston, told attendees at the FDA’s Infusion Pump systems for use by caregivers when writing prescriptions, Workshop that his hospital spends about $500,000 a year with clinical decision support to make sure IV medica- to service infusion pumps. That translates into spending tions are ordered correctly. 45 percent of his department’s service costs on just 16 “And we have a ‘bedside barcoding’ system to ensure percent of its inventory. the ‘five rights’ of medication administration are always correct,” adds Sims. The five rights are: right patient, Early Answers right route, right dose, right time, and right medication. On April 30, 2010, the FDA sent a letter to Baxter Health- An early adopter of smart pumps, MGH has had the care Corporation ordering the company to recall and devices in their intensive care units, operating rooms, pe- destroy all models of its Colleague Volumetric Infusion diatric, and general-care areas since the mid-1990s. “We Pumps. As many as 200,000 of the pumps were estimated believe very strongly in standardization of drugs, clinical to be in use in the United States at the time. While the protocols, and drug libraries.”
Biomedical Instrumentation & Technology 375 COVER STORY First, Do No Harm: Making Infusion Pumps Safer
At the Duke University Health System, several dif- Training someone not to make mistakes ferent kinds of smart pumps are in use and, says Scales, isn’t“ effective. You can’t do it. We’re humans, “each was selected, configured, and implemented by a not machines. We’re not programmed team with experts selected for their expertise in the new to do the right thing every time.” modality.” Pumps were selected for neonatal air trans- —Tony Easty, senior scientist, Centre for port, epidural and regional pain management, IV pain Global eHealth Innovation management, and magnetic resonance imaging cardiac stress testing. In addition, a multidisciplinary group that includes pharmacists, nursing practice experts, nurse educators, and clinical engineers routinely reviews data extracted from the smart pumps to look for failure modes pump malfunction has decreased markedly as a result of and improvements to drug libraries. “Part of this review,” redesigned user interfaces, Guardrails,®8 and other ergo- explains Scales, “includes an analysis of how ‘smart pump’ nomic features that have been implemented as a result of libraries work in conjunction with our CPOE system.” sentinel events with PCA pumps,” he says. When errors occur, the organization has a system in But real progress, according to Overdyk and others, place to respond. “All device-related medication errors is only going to be made when people stop looking at and adverse drug events are reviewed by a clinical pharma- infusion pumps as “stand-alone” devices. cist and a clinical engineer who collaborate on causes and recommendations for improvement,” explains Scales. Making the Connection In addition to hospital initiatives, manufacturers “Stand-alone devices won’t work,” states Husch, who sees have responded to reported problems with technology the solution to infusion pump problems as being part of a enhancements and design improvements. Overdyk cites larger issue of connectivity: enabling interaction between enhancements in PCA devices. “The number of cases I electronic medical records, infusion pumps, monitoring have reviewed involving errors in pump programming or devices, and other technology. A tall order—but possible,
AAMI Takes Aim The Association for the Advancement of Medical In- nization or hospitals to take all the strumentation (AAMI) is working with FDA to bring burden. We have to do it together.” together regulators, manufacturers, device users, and The FDA’s new focus on infusion others to discuss infusion pump safety issues and pos- pumps has led to a revitalized AAMI sible solutions. Infusion Device Committee. Mas- The two groups are hosting a summit, scheduled to sachusetts General Hospital’s Nat take place Oct. 5 and 6. “The scope of the problem is Sims, MD, and Baxter International vast and requires a broad, multifocused approach,” says Inc.’s Pat Baird serve as co-chairs of Nat Sims AAMI Infusion Device Committee Member Glenn the group. Scales, a CBET with Duke University Health System. Sims says the committee has al- A summit, he says, is a “very good first step” toward ready begun work “to improve the finding solutions. national and international standards “AAMI needs to step it up,” says association Presi- that govern how infusion pumps are dent Mary Logan. According to Logan, today’s pump designed.” The committee is also standards didn’t anticipate the complexity of interre- looking to create a safety panel of in- lated systems. dustry and regulatory experts to find Pat Baird “Standards are an answer to some of the complex ways to minimize adverse events. challenges, certainly not all,” says Logan. “No one of If you are interested in joining the AAMI Infusion us can take that burden. It’s not fair for the FDA, it’s not Device Committee, contact Jennifer Moyer at jmoyer@ fair for industry, it’s not fair for standard-setting orga- aami.org, or call 703-253-8274.
376 September/October 2010 COVER STORY Jody Lannen Brady
she believes. In many cases, industry has responded “There are all sorts of legal and proprietary barriers “ to adverse events by enhancing to achieving connectivity, but I believe it’s achievable. pump safety features.” It’s just going to require more regulatory oversight so —Bona Benjamin, the American Society of that we can create the universal, ubiquitous standards Health-System Pharmacists we need,” says Husch. For example, existing medical re- cord frameworks like HL7—standards for the exchange, integration, sharing, and retrieval of electronic health information—exist in “so many versions that they’re es- for integration between PCA pumps and monitors for sentially meaningless,” she explains. early detection of respiratory depression, or failure to Experts agree that integration of electronic medical breathe adequately. Overdyk, too, believes that an es- records with infusion pump functionality will prove a vi- sential component of improving infusion pump safety is tal step in reducing dosage errors. “We would like to have to integrate infusion pumps with monitoring equipment. better ‘wireless connectivity’ between pumps and clinical “Since infusion pumps may administer a potentially toxic information systems, so we can know with certainty that substance—like morphine, potassium, or heparin—an every drug infusion is being given in accordance with the intuitive safety feature to me is to ‘close the loop’ by mea- original order for that specific patient,” says Sims. Going suring the drug’s effect on things such as respiratory rate, one step further, Scales says healthcare providers need oxygen saturation, and carbon dioxide levels.” “the ability to import data from infusion pumps into Some work is already being in done in this direc- medical records.” tion. Overdyk points to PCA pumps that offer oximetry “Our challenge is getting the pumps to talk to other interfaces,” concurs Easty. Want More Information? In the case of multiple drug infusions, this might To get more details on infusion pump safety, check take the form of technology that links particular bags of out these sites: medication to particular channels of an infusion pump so AAMI Hot Topics that, for example, a drug that needs to drip intravenously http://www.aami.org/hottopics/ couldn’t accidentally be piggybacked below the drip, al- lowing free flow of the drug into the patient. ASHP IV Safety Summit Integrating emerging barcoding technology with http://www.ashp.org/iv-summit smart pump technology offers promise here. Sims says FDA Infusion Pump Improvement Initiative that he would like every IV drug container to have a www.fda.gov/MedicalDevices/ barcode that can be recognized by a drug infusion pump ProductsandMedicalProcedures/ to ensure 100 percent accuracy. In addition, pumps with GeneralHospitalDevicesandSupplies/InfusionPumps barcoding technology have already proven useful in Centre for Global e-Health Innovation reducing “wrong patient” errors, according to a recent www.ehealthinnovation.org/?q=node/365 study—though the same study concluded that “until bar- Institute for Safe Medication Practices code pumps are integrated with other systems within the http://www.ismp.org/ medication administration process, their role in enhanc- ing patient safety will be limited.”9 San Diego Patient Safety Consortium “I feel that barcode medication administration will, if http://www.nichq.org/pdf/ implemented correctly, dramatically reduce errors,” Scales AppendixDSanDiegoPatientSafetyConsortium.pdf agrees. “However, this is expensive and the implementation Intravenous Medication Safety and Smart must incorporate many areas beyond the pump design— Infusion Systems including information systems, pharmacy, materials, and http://www.patientsafetyresearch.org/ the institution’s supply chain. The implementation of this journal%20articles/Int_Med_Safety.pdf kind of system requires much long-term planning from ECRI Institute many diverse stakeholders to ensure success.” https://www.ecri.org/Pages/default.aspx Another key connectivity issue Sims sees is the need
Biomedical Instrumentation & Technology 377 COVER STORY First, Do No Harm: Making Infusion Pumps Safer
terfaces” is critical to helping prevent dosing errors, says Scales.
Next Steps Even before issues of connectivity and interoperability are worked out, experts see a host of shorter-term actions that should be taken. According to ASHP’s Benjamin, a critical challenge is determining “how to ‘road test’ devices, so that the de- sign flaws can be exposed and corrected.” While Benja- min doesn’t assert that it’s possible to predict everything that could go wrong with a pump, she believes that “a rigorous testing process in realistic conditions needs to be developed.” Peter Doyle, a human factors engineer, also sees the need for more rigorous design-phase testing of infusion pumps. “I strongly support the need to involve human factors expertise during design and to conduct usability testing during various phases of design development to ensure that representative users will be able to use the pumps reliably in the environments of use,” says Doyle of Johns Hopkins Hospital’s Clinical Engineering Services. FDA has begun work in this area. “Particularly en- couraging is the Infusion Pump Initiative and its focus on testing pumps in a real-world environment,” Benjamin says. Sims agrees: “We applaud the FDA’s efforts to add more rigor to the design development and premarket
Dr. Nat Sims, examining a disposable plastic syringe in his laboratory at submission [510(k)] process.” Massachusetts General Hospital in Boston, says FDA is moving in the right As part of its initiative, FDA is requesting additional direction with “more rigor” in its review process for infusion pumps. validation for infusion pump submissions, specifically Credit: Joshua Touster Photography simulation testing prior to a clinical evaluation. “Simu-
(SpO2) and capnography (EtCO2) monitoring modules. lated use testing is necessary to ensure sufficient safety One early adopter, St. Joseph’s/Candler Health System and effectiveness prior to the clinical evaluation,” Ron in Savannah, GA, resported preventing 328 potentially Kaye of FDA told attendees at the agency’s May work- serious overdoses in six months with the monitoring shop on infusion pumps. modules in place.10 Design improvements are needed for both hardware Recent developments with electronic medication ad- and software, say experts. “Software designs need to bet- ministration record (eMAR) systems that have demon- ter address how and why errors are made and why the strated “success data” for non-intravenous medications device operator is seemingly unaware of how and why the show promise for infusion pumps, as well. “As soon as error occurred until the patient’s physiological condition real-time data from infusion pumps connected to a par- makes it known,” says Scales. Potential hardware refine- ticular patient are auto-documented into eMAR records ments include enhancing battery life, preventing fluid in- for that patient, it will be possible to ‘close the loop’ and filtration, and designing “more robust” pump accessories prove safe care,” says Sims, who points to systems suc- that can “stand up under typical use,” he adds. cessfully implemented at hospitals such as Intermountain Manufacturers are already responding to these chal- Health Care in Salt Lake City and Lancaster General lenges, says Benjamin. “In many cases, industry has Hospital in Pennsylvania. responded to adverse events by enhancing pump safety Put simply, the “development of interoperability in- features,” she says. Overdyk concurs: “Certainly the user
378 September/October 2010 COVER STORY Jody Lannen Brady
interface has been improved in infusion pumps, making healthy competition is maintained in the industry.” programming errors less common. Pump malfunction Even with better pump designs, healthcare institutions incidence has also been reduced.” must take responsibility for patient safety, says Scales: In addition to improving patient outcomes, reducing “The key to these issues is having an established safety infusion pump incidents means savings for hospitals. culture and a relationship between clinical engineering Each preventable adverse drug event (ADE) has been and the front-line caregivers that ensures that when inci- reported to cost $8,750. At St. Joseph’s/Candler Health dents occur, they are reported promptly—within minutes, System, the purchase of a $1.5-million IV safety system not days— that evidence is preserved and documented, resulted in an estimated reduction of 471 ADEs over a and that all the interested parties actively participate in five-year period that, if not averted, would have resulted finding long-term solutions.” in potential costs to the hospital of almost $4 million, In addition, institutions may need to re-examine staff- yielding an estimated 5-year return on investment of ing and monitoring standards on general-care floors in $1.8 million.11 order to reduce infusion pump sentinel events. In a recent Sims sees additional potential in further opening the editorial, Overdyk wrote: “Infrequent patient monitor- door to foreign device companies. “I think it would be ing, with intervals as far apart as every four hours on the useful to have more competition in the infusion device in- first postoperative night, is a major reason for the persis- dustry. Competition leads to higher quality in device de- tence of these events. ‘Failure to rescue’ is a misnomer, sign and lower prices, when hospitals have more choices,” since it is not a failure of the code team to resuscitate, but he says. Sims looks to European manufacturers of drug a ‘failure to recognize’ respiratory decompensation in a infusion pumps, who make more than 100,000 pumps timely fashion.”12 per year for many countries throughout the world—just As long-term solutions are developed, the FDA is not the United States. “We need to ensure that vigorous asking clinicians to take general precautionary steps:
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Biomedical Instrumentation & Technology 379 COVER STORY First, Do No Harm: Making Infusion Pumps Safer
Establish a plan to prevent known pump problems and 4. 2009 Pharmacy Practice in Hospital Settings: Monitoring to respond in the event of pump failure, label infusion and Patient Education. American Society of Health-System pump channels and tubing to reduce errors, monitor Pharmacists. 5. Husch M, Sullivan C, Rooney D, et al. “Insights From the patients closely for signs of over- or under-infusion, and Sharp End of Intravenous Medication Errors: Implications report adverse events promptly to the agency. for Infusion Pump Technology,” Quality & Safety in Health Care. 2005; 14. With more infusion pumps in hospitals today than 6. Trbovich P, Pinkney S, Cafazzo J, et al. “The Impact of Tradi- any other device, their safety record—despite some im- tional and Smart Pump Infusion Technology on Nurse Medi- provements over the years—remains a call to action. On cation Administration Performance in a Simulated Inpatient Unit,” Quality & Safety in Health Care. 2010. the horizon are more robust FDA oversight, new safety 7. Guidance for Industry and FDA Staff - Total Product Life Cy- standards to reflect current technology and practices, cle: Infusion Pump - Premarket Notification [510(k)] Submis- human factors-driven design improvements, and univer- sions. U.S. Food and Drug Administration. 2010. 8. CareFusion’s Guardrails® Suite MX Safety software. sal standards for interoperability of devices. n 9. Trbovich P, Pinkney S, Cafazzo J, et al. “The Impact of Tradi- tional and Smart Pump Infusion Technology on Nurse Medi- References cation Administration Performance in a Simulated Inpatient 1. Husch M, Sullivan C, Rooney D, et al. “Insights From the Unit,” Quality & Safety in Health Care. 2010. Sharp End of Intravenous Medication Errors: Implications 10. “Intravenous Infusion Safety Initiative Prevents Medication for Infusion Pump Technology,” Quality & Safety in Health Errors, Leading to Cost Savings and High Nurse Satisfaction,” Care. 2005; 14. AHRQ Health Care Innovations Exchange. 2009. http://www. 2. Kinnealey E, Fishman G, DeMonaco H, et al. “A Solution innovations.ahrq.gov/content.aspx?id=2375 for Safer Intravenous Drug Delivery at the Point of Care: A 11. Danello S, Maddox R, and Schaack G. “Intravenous Infusion Team Approach,” Focus on Patient Safety Newsletter, 2003; Safety Technology: Return on Investment,”. Hospital Phar- 6 (1). macy Journal. 2009; 44 (8). 3. Leape L, Brennan T, Laird N, et al. “The Nature of Adverse 12. Overdyk, F. Letter to the Editor: “Postoperative Opioids Events in Hospitalized Patients: Results of the Harvard Medi- Need System-Wide Overhaul,”. Anesthesia Patient Safety cal Practice Study II,” New England Journal of Medicine. Foundation Newsletter. 2010; 24 (4). 1991; 324(6).
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