Give Intravenous Bolus Overdose a Brake: User Experience and Perception of Safety Device

• Published in: Journal of patient safety Vol. 17; no. 2; pp. 108 - 113
• Main Authors: Ng, Yasmin Yen Yen, Wan, Paul Weng, Chan, Kim Poh, Sim, Guek Gwee
• Format: Journal Article
• Language: English
• Published: United States Lippincott Williams & Wilkins 01-03-2021; Copyright Wolters Kluwer Health, Inc. All rights reserved
• Subjects: Cross-Sectional Studies; Humans; Infusions, Intravenous - adverse effects; Medication Errors - prevention & control; Original Studies; Perception; Protective Devices - standards
• ISSN: 1549-8417; 1549-8425
• DOI: 10.1097/PTS.0000000000000770

OBJECTIVESDrugs can come in concentrated solutions that require dilution before intravenous bolus administration. Upon dilution, the syringe can contain more than the required amount of drug. The user may mistakenly administer the full contents of the syringe, resulting in an overdose. In this cross-sectional study, we evaluated user experience and perception of Syringe Brake, a dosage flow restrictor device, as part of the intravenous morphine bolus administration workflow.
METHODSFrom December 2018 to January 2019, doctors and nurses working in the emergency department of 3 public tertiary hospitals in Singapore were invited to complete a paper-based 11-item 5-point Likert scale survey questionnaire after 3 months of Syringe Brake implementation.
RESULTSOverall, 77.5% (290/374; 4.11 ± 0.83) of participants were satisfied with the use of Syringe Brake to prevent medication error. Our survey results showed that the top features of Syringe Brake were ease of setting the desired volume to be administered (86.1%; 4.21 ± 0.72), allowing the drug to be titrated safely (84.8%; 4.26 ± 0.77), and giving users the confidence to avoid overdosing the patient (82.1%; 4.21 ± 0.78). Those with hands-on experience with Syringe Brake rated significantly higher for all survey statements except on the perceived ability to prevent error arising from miscommunication (adjusted odds ratio, 1.58 [0.98–2.57]; P = 0.062).
CONCLUSIONSSyringe Brake shows promising potential for adoption to prevent medication errors. The device serves as a constraint to prevent accidental overdose, caused by user unfamiliarity or autopilot administration.