Striving for Zero IV Pump Errors: A Unique Approach

April 6, 2016

Summary

After noting an increased trend in IV pump events, a Failure Mode Effects Analysis (FMEA) was conducted to determine the contributing factors that were causing colleagues to program pumps incorrectly. Based on the findings, an acronym titled “LITER” was adapted to assist with the correct programming of pumps.

In this session, Lehigh Valley Health Network's Medication Safety Officer and Patient Safety Officers will describe the acronym and steps taken to avoid IV Pump Events.

The objectives for this webinar are:

  • Identify trends obtained through patient safety reporting regarding IV pump events.
  • Recognize the use of a FMEA to determine breakdown in the process contributing to IV pump events.
  • Analyze success of FMEA through monitoring IV pump events after implementation of LITER 

Speakers

Kristie Lowery, Director of Patient Safety
Lehigh Valley Health Network

Leroy A Kromis III, Medication Safety Officer
Lehigh Valley Health Network

Gwenis L. Browning, Patient Safety Officer
Lehigh Valley Health Network

Kristie Lowery is Director of Patient Safety at Lehigh Valley Health Network, a regional trauma center located in Allentown, Pennsylvania. She is responsible for implementation and compliance of the Pennsylvania Medical Care Availability and Reduction of Error Act which requires mandatory reporting of patient safety events. Kristie is responsible to investigate serious patient safety events, conduct a root cause analysis and develop an appropriate action plan. Trends are reviewed and interventions developed to decrease the risks and assure safe care for the patients.

Leroy A Kromis III is the Medication Safety Officer at Lehigh Valley Health Network (LVHN) in Allentown, PA and has held the position for the last 10 years. He received his BS in Pharmacy in 1996 and his Doctorate in Pharmacy in 1997 from the University of North Carolina at Chapel Hill. He began his career in acute care hospital pharmacy in 1994 at Duke University Hospital in Durham NC as a pharmacy technician. After completing his BS, Leroy moved up to a clinical pharmacist, specializing in post cardiac surgery care. In 2002, he took a position as a Pharmacy Clinical Coordinator at Easton from 2002 to 2005 and served on Easton Hospital’s Institution Review Board as a member from 2002 to 2004 and was appointed Chairman from 2004-2005. Leroy was a member of both LVHN’s Institutional Review Boards from 2005 until 2012. He was appointed Chairman of both LVHN’s IRBs in October 2014. Leroy obtained his Board Certification in Pharmacotherapy in 2009. He also enjoys teaching the next generation of students as a preceptor for three pharmacy schools and medication safety lecturer in eastern Pennsylvania.

Gwenis L. Browning is a Patient Safety Officer for Lehigh Valley Health Network in Allentown, PA. She graduated in 2000 from Bloomsburg University, PA and entered an internship in the Operating Room. She was a staff nurse prior to accepting a leadership role that included reviewing patient safety events and following up on events that occurred in the perioperative arena. She expanded her nursing career by transitioning to Risk Management in 2010 and prior to being offered the opportunity to be a Patient Safety Officer. Gwen obtained her Masters in Nursing Administration from Drexel University, Pa in 2013. She has assisted in maintaining compliance of the Pennsylvania Medical Care Availability and Reduction of Error Act which requires mandatory reporting of patient safety events, investigations, root cause analyses and action plans. In addition to obligatory requirements, she also focuses on tracking and trending events and investigating process concerns to change systems to enhance patient safety.

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