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hydromorphone-alerts

Med O.S.® for Infusion Safety Network Result

Investigating Hydromorphone Alerts to Identify Outlier Impact

Study Overview

Situation

A large community hospital noticed a significant increase in infusion pump alerts for hydromorphone over a short period of time, which was a new trend for this medication entry.

Business Case & Findings

Monitoring controlled substances and high-alert medications is a regulatory expectation. Bainbridge Health discovered that the majority of alerts stemmed from a single drug library entry across two infusion pumps, indicating that one outlier patient was contributing to the sudden increase in alerts and overrides, and there was not a systemic deviation in practice.

Results

Bainbridge Health recommended against making any drug library intervention in light of a single outlier patient. Upon patient discharge, the hospital observed an immediate improvement in its hydromorphone alert trend, avoiding unnecessary drug library modifications while maintaining safe dosing limits.

Situation

A large community hospital noticed a significant increase in infusion pump alerts for hydromorphone over a short period of time, which was a new trend for this medication entry. As a high alert opioid medication, any increase in alert patterns raises red flags around potential medication safety risks, deviance in expected administration guidelines for use, and the possibility of drug library misalignment. Concerned that the alert surge could indicate a systemic issue—or lead to alert fatigue and overrides—the hospital’s pharmacy and medication safety leaders sought support in further analysis to determine the root cause and potential interventions.

Business Case

  • Alert fatigue is an established driver of medication errors and nursing burnout. Numerous regulatory bodies and thought leaders (including the ECRI Institute and The Joint Commission) cite alert fatigue as one of the most prevalent causes of patient harm in hospitals.1,2
  • Joint Commission Standards require that hospitals monitor and promote safe use of opioid medications, including analyzing data to increase quality and safety of administration.3
  • Leadership engaged Bainbridge Health to support the Pharmacy and Medication Safety teams in analyzing data for high-risk entries to detect deviations in administration outside of institutional guidelines for use.

Intervention & Impact

Bainbridge Health leveraged the Med O.S.® platform to analyze the recent hydromorphone alert trend and discovered that there was an acute 800% increase in alerts for this entry compared to the previous month, a majority of which occurred on only two infusion pumps. This pattern indicated that one outlier patient was contributing to the sudden increase in alerts and overrides. Bainbridge Health confirmed that the hospital’s drug library limits were properly aligned with network benchmarks and recommended that the hospital take no action to amend its drug library.

Within the month, the hospital observed an immediate reduction in its hydromorphone alert trend, returning to its baseline, and was able to avoid unnecessary drug library modifications.

hydromorphone-alerts

Figure: Identification of outlier alerts

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Disclaimer

This example is for information purposes only and should not be relied upon to make specific clinician decisions.

All clinical opportunities identified by Bainbridge Health were evidence-based according to supporting literature and network data. They were also made under the surveillance of the Bainbridge Health Clinical Solutions team, an interdisciplinary group of subject matter experts who provide guidance and oversight.

References

  1. The Joint Commission (TJC). Optimizing smart pump safety with DERS. TJC Sentinel Event Alert. 2021; 63.
  2. Institute for Safe Medication Practices (ISMP). Survey results: Smart pump data analytics. Acute Care ISMP Medication Safety Alert. 2018; 23(14).
  3. The Joint Commission (TJC). Leadership standard LD.04.04.05: Policies and procedures based on law and standard practice.