Shivesh Prakash, Ruth M Sladek, Lambert Schuwirth
Interventions to improve diagnostic decision making: A systematic review and meta-analysis on reflective strategies
Medical teacher
intravenous infusions potential cause significant harm patients associated high rate adverse drug events medication errors infusion pumps dose error reduction software ders used reduce errors establishing safe infusion parameters 2019 quality improvement project initiated aim increase ders compliance 46 75 specialty institution october 1 2022 interdisciplinary group tasked improving compliance ders identifying key drivers including informed staff engaged staff accurate smart pump library used model improvement framework guide improvement project plandostudyact pdsa cycles used plan interventions pdsa cycles included drug library updates education unitlevel compliance reporting weekly average ders compliance monitored outcome measure weekly pump alerts per 100 infusions monitored balancing measure statistical process control charts used monitor measures 2018 2022 course 25 months 8 pdsa cycles resulted 5 centerline improvements baseline mean 46 final mean 78 pump alerts per 100 infusions decreased 159 64 first pdsa cycle continued decrease 39 subsequent interventions although features like ders help ensure safe medication administration continuous improvement efforts increase ders compliance without increasing alert burden needed ensure benefits technology optimized