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MODULE 31: SMART PUMPS & PRACTICAL TROUBLESHOOTING
Section 31.2: Common Safety Drifts: rate/unit mix-ups, mcg/kg/min vs mL/hr
Identifying and correcting the subtle deviations from best practice that lead to major errors.
SECTION 31.2
Common Safety Drifts: The Hidden Currents of IV Errors
Understanding the gap between “work-as-imagined” and “work-as-done.”
31.2.1 The Anatomy of a Drift: Beyond Simple Mistakes
In the world of safety science, we often focus on active errors—a slip, a lapse, a mistake made by an individual at a single point in time. But a far more common and insidious threat to patient safety is the phenomenon of “practical drift.” This is the slow, incremental, and often invisible divergence of everyday practice from the established, written procedure. It’s not a single, malicious act of non-compliance; it’s a gradual normalization of deviance, where a small shortcut, taken once to solve a problem, becomes a habit, then a team-wide norm, and eventually, the new, unwritten standard of practice. It represents the growing gap between work-as-imagined (the official policy, the procedure manual, the drug library design) and work-as-done (what actually happens at the bedside at 3 AM on a busy Saturday night).
Smart pumps are designed to be rigid, to enforce the “work-as-imagined” model. They are a technological control intended to prevent deviation. However, healthcare is a complex adaptive system, and frontline clinicians are masters of adaptation. When faced with a cumbersome workflow, a STAT order, or a pump that seems to be “in the way,” they will find workarounds. These workarounds are almost never born from laziness or malice; they are born from a desire to be efficient and provide timely patient care. The nurse who bypasses the drug library to start a vasopressor in “mL/hr” mode isn’t trying to be unsafe; she’s trying to get a life-saving medication started 30 seconds faster for a crashing patient. But in doing so, she unknowingly strips away every single safety feature you so carefully built into the library.
This section is a masterclass in identifying these drifts. Your role as the pharmacist is not to be a police officer, punishing people for using workarounds. Your role is to be a safety detective, to understand why the drift is happening. Is the library too slow? Is the naming convention confusing? Is there a gap in the available concentrations? Every drift is a symptom of an underlying system problem. By spotting the drift, you can diagnose the problem and re-engineer the system to make the safest path the easiest path once again. As stated by human factors expert Dr. Sidney Dekker, “Human error is not the cause of failure, but a symptom of it.” Our mission is to find and fix those deeper system failures.
Retail Pharmacist Analogy: The “Shortcut” on the Path
Imagine your pharmacy has a strict policy: every C-II prescription must be double-counted by two different people, and both must sign the back of the hardcopy. This is the official path, paved and well-lit. It’s work-as-imagined.
One day, during an insane rush, a new pharmacist is working with a very experienced technician. They fill an OxyContin script. The pharmacist counts it, then hands the bottle and script to the technician and says, “Here, just initial next to my name, I’m slammed.” The technician, trusting the pharmacist, signs without recounting. They just took a small shortcut through the grass. It saved them 45 seconds.
The next day, it happens again. Soon, it becomes their normal workflow. A new technician sees them doing it and learns this “more efficient” way. Over a year, the well-lit, paved path is overgrown with weeds from disuse. A new, well-worn dirt path has formed in the grass. This shortcut is now the norm. It is work-as-done. The team sees it not as a violation, but as the “smart” way to work.
This is a practical drift. Everything is fine for a year. Then, one day, the pharmacist is distracted and miscounts 90 tablets as 60. The technician, following the drifted norm, signs without recounting. The patient goes home with the wrong quantity, and two weeks later you have a DEA audit triggered by an early refill claim. The system failure wasn’t the single miscount; the failure was the months-long, uncorrected drift away from the safe, established process.
Bypassing the smart pump drug library is the clinical equivalent of taking that shortcut. Your job is to spot the new dirt path being formed and ask “Why are people walking on the grass?” The answer will lead you to a way to make the paved path faster, smoother, and the only one anyone ever wants to take.
31.2.2 The Great Divide: Communicating in “Dose” while Programming in “Rate”
The most significant safety drift in IV therapy originates from a fundamental cognitive gap. Physicians think, order, and communicate in the language of dose (e.g., “Start norepinephrine at 0.05 mcg/kg/min and titrate to a MAP of 65”). Nurses, at the end of the line, must translate that clinical intent into the mechanical language of the pump: rate (mL/hr). The smart pump library is designed to be the universal translator, performing this high-risk calculation automatically and flawlessly every single time.
When a clinician bypasses the library and programs the pump in its “basic infusion” or “mL/hr” mode, they are choosing to become a manual calculator. They are taking on the cognitive load of a complex, multi-step dimensional analysis, often in a high-stress environment, at the bedside of a critically ill patient. This is the single most dangerous drift, as it deactivates all the dose-based safety limits you have built. The pump no longer knows it’s infusing norepinephrine; it only knows it’s pushing fluid at a certain speed. It cannot warn the user that a rate of 100 mL/hr is a massive overdose because it has no clinical context. The “smart” pump has been rendered dumb.
Masterclass Scenario: The Manual Mode Tragedy
The Situation: An 80kg patient is hypotensive. The physician yells, “STAT, start a Levo drip at 10 mcg/min!” The nurse grabs the standard bag (8 mg in 250 mL, which is 32 mcg/mL).
The Drifted Workflow (Work-as-Done): To save time, the nurse decides to program in mL/hr. She needs to calculate the rate. The desired dose is 10 mcg/min. First, she must convert this to mcg/hr: $$10 \text{ mcg/\min} \times 60 \text{ \min/hr} = 600 \text{ mcg/hr}$$ Now, she must divide by the concentration: $$\frac{600 \text{ mcg/hr}}{32 \text{ mcg/mL}} = 18.75 \text{ mL/hr}$$
The Error Under Pressure: In the heat of the moment, she makes a common mental math slip. She forgets to convert the per-minute dose to per-hour. She calculates: $$\frac{10 \text{ mcg/\min}}{32 \text{ mcg/mL}} = 0.3125 \text{ mL/\min}$$ Still thinking in minutes, she knows she needs mL/hr, so she multiplies by 60: $$0.3125 \text{ mL/\min} \times 60 \text{ \min/hr} \approx 18.75 \text{ mL/hr}$$ She gets the right answer, but through a convoluted and error-prone process. But what if she made a different error?
The Catastrophic Error: She forgets the entire second step. Flustered, she simply takes the dose, 10 mcg/min, and enters **10 mL/hr** into the pump. The patient is now receiving: $$10 \text{ mL/hr} \times 32 \text{ mcg/mL} = 320 \text{ mcg/hr}$$ $$320 \text{ mcg/hr} div 60 \text{ \min/hr} = 5.3 \text{ mcg/\min}$$ This is a 50% underdose. The patient’s blood pressure continues to drop.
The Opposite Catastrophe: In her haste, she makes a decimal error on the concentration (or misremembers it) and calculates based on 3.2 mcg/mL instead of 32 mcg/mL. She programs the pump to **187.5 mL/hr**. The patient receives a ten-fold overdose and develops life-threatening tachyarrhythmias.
The Library Workflow (Work-as-Imagined): The nurse selects NOREPINEPHRINE (LEVO) from the ICU library. She enters the patient’s weight (80 kg). She selects the dosing unit “mcg/min.” She enters the ordered dose, “10.” The pump instantly calculates and displays “18.8 mL/hr” and begins the infusion. It is nearly impossible to make a calculation error. The entire process is safer, faster, and more reliable.
Why Does This Drift Happen? The Pharmacist’s Investigation.
When you see from your CQI data that your hospital has a high rate of “basic” (non-library) infusions for high-alert drugs, you must investigate. The reasons are often systemic and reveal opportunities for improvement.
| Common Cause of Drift | How to Investigate | Pharmacist-Led Solution |
|---|---|---|
| The Library is Too Slow or Cumbersome | Talk to your nurses. Shadow them. Time how long it takes to program a common drip. Count the number of button presses required. Is finding the drug difficult? | Work with your vendor and informatics team to streamline the workflow. Can you create “Quick Start” entries? Can you organize the drug list more intuitively? |
| Missing Drugs or Concentrations | Review override logs. Are nurses frequently bypassing the library for a specific drug? It’s likely because that drug (or its correct concentration) doesn’t exist in the library. | This is a direct call to action. A missing entry in the library is a critical gap. Initiate the process to build, test, and add the missing entry as a top priority. |
| Lack of Training / New Staff | Look at compliance data by unit and by shift. Is non-compliance higher on nights, or on a unit with many new graduate nurses or travelers? | Develop a “just-in-time” training tool—a simple, laminated card attached to the pump with a 3-step guide to using the library. Work with nurse educators to ensure pump training is a mandatory part of orientation. |
| Cultural Normalization (“This is how we’ve always done it”) | This is the hardest to detect and fix. It requires rounding and direct observation. You may hear phrases like “Oh, we never use the library for drips in the ED, it’s too slow.” | This requires a top-down and bottom-up approach. Present compliance data to nursing leadership to get their buy-in for a culture change. At the same time, work at the elbow with frontline staff, showing them how the library protects them and their patients. Frame it as a professional standard of care. |
31.2.3 The Treacherous Terrain of Units: Micrograms vs. Milligrams vs. “Units”
A second, equally dangerous drift occurs with dosing units. Even within the drug library, the potential for error exists if the user selects the wrong unit or misinterprets the order. A simple mix-up between “mg” and “mcg” is a 1000-fold error. A mix-up between “units/hr” and “mL/hr” for an insulin drip can be a 100-fold overdose. As the library architect, your job is to build guardrails that make these mix-ups as difficult as possible.
Masterclass Table: The Most Lethal Unit Mix-Ups
| Drug Class | The Mix-Up | Consequence | Pharmacist’s “Street Smarts” Prevention Strategy |
|---|---|---|---|
| Insulin | Programming in mL/hr instead of the required units/hr. | 100-Fold Overdose. Standard insulin drips are 100 units in 100 mL (1 unit/mL). An order for 2 units/hr, if programmed as 2 mL/hr, is correct. But if the bag is 100 units in 100 mL and a nurse programs a rate of 10 mL/hr, they are delivering 10 units/hr, not 10 mL/hr. The most dangerous scenario is if the concentration is U-500. |
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| Heparin | Programming in mL/hr instead of units/hr. | 100-Fold Overdose. Identical risk to insulin. Standard heparin bags are 25,000 units in 250 mL (100 units/mL). An order for 1200 units/hr should be a rate of 12 mL/hr. If the nurse programs 1200 mL/hr, the patient receives the entire bag in minutes. |
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| Vasopressors & Inotropes (e.g., Dopamine, Dobutamine) | Mixing up mcg/kg/min with mg/kg/min (a slip in the EHR) or mcg/min. | 1000-Fold Overdose (mcg vs mg) or Major Dose Error (flat vs weight-based). A typo in the order can lead to a nurse programming a lethal dose. An order for Dopamine “5 mg/kg/min” instead of “5 mcg/kg/min” is catastrophic. |
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| Sedatives (e.g., Midazolam) | Mixing up mg/hr (correct for Midazolam) with mcg/kg/min (used for Propofol/Dexmedetomidine). | Massive Dose Discrepancy. A nurse accustomed to titrating propofol in mcg/kg/min may try to apply the same logic to midazolam, which is ordered in a flat mg/hr dose. This leads to confusion and potential error. |
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31.2.4 The Pharmacist’s Playbook: Actively Hunting and Reversing Drift
You cannot wait for an adverse event to reveal a safety drift. As the pharmacist, you must be a proactive “drift hunter.” This requires a combination of data analysis and old-fashioned, at-the-bedside detective work. This is where your clinical expertise intersects with your role as a systems thinker.
The Safety Gemba Walk: Proactive Drift Hunting
In quality improvement, a “Gemba walk” means going to the actual place where the work is done to observe and learn. For you, this means getting out of the central pharmacy and rounding in your critical care units with a specific mission: to observe the human-pump interaction.
- Go to the Bedside: Pick a few ICU rooms. Introduce yourself to the nurse: “Hi, I’m [Name] from pharmacy. I’m doing some safety rounds on our pumps. Would you mind if I just took a quick look at your infusions?”
- Look at the Pump Screen: What does it say? Does it show the drug name (e.g., “NOREPINEPHRINE”) at the top? If so, the library is being used. This is a win. If it just says “Basic Infusion” or shows only a rate in mL/hr, you have found a drift.
- Cross-Reference the Order: Look at the order in the EHR. Look at the pump. Does the dose match? Is the patient’s weight in the pump the same as the most recent weight in the chart? A mismatch is another form of drift.
- Ask “Why” with Curiosity, Not Judgment: If you find a drift, this is your chance to learn.
- Good Question: “Hey, I noticed we’re running the Levo in basic mode. Is there a reason for that? Sometimes the library can be a pain, and I’m trying to gather feedback to make it better.”
- Bad Question: “Why aren’t you using the drug library? You know that’s the policy.”
- Correct and Educate in the Moment: Use the opportunity to fix the immediate problem and provide just-in-time education. “Let’s quickly reprogram this through the library so we have the safety limits active. Can I walk you through it? It’ll just take a second.” You have just reversed one drift and helped one clinician improve their practice.
Using CQI Data to See the Invisible
Your pump’s CQI data is like a satellite map of all the shortcuts being taken in your hospital. You must schedule time every month to review this data with your IV safety committee. You are looking for patterns that indicate a larger drift.
- High Compliance is Goal #1: Your primary metric is “Drug Library Compliance Rate.” This is the percentage of infusions that are programmed through the library. The ISMP goal is >95%. If your hospital is at 80%, you have a major, systemic drift. Your data can often show you which units or shifts have the lowest compliance, allowing you to target your interventions.
- Overrides are Breadcrumbs: A high number of “soft limit” overrides for a particular drug is a huge signal. It tells you one of two things: either your limits are wrong (set too low, causing nuisance alerts), or clinicians are routinely practicing outside the institution’s accepted norms. Both possibilities require investigation and a committee-level discussion.
- Manual Reprogramming: Look for data on how often a dose is changed or the pump is reprogrammed. Are there drugs where the dose is being changed every 5 minutes? This may indicate a flaw in the titration parameters or a need for a different medication.
By combining your proactive, at-the-bedside observations with reactive, systematic data analysis, you can get a complete picture of the safety drifts occurring in your institution. This allows you to move from being a reactive problem-solver who responds after an error to a proactive system architect who prevents errors from ever reaching the patient.
