SmartPump Audit

From CCMDB Wiki
Jump to navigationJump to search
Active?: legacy
Program: CC and Med
Requestor: Linda Hathout
Collection start: 2008-03-03
Collection end: 2008-03-25

Legacy only, see below for details


The Smart Pump Audit records usage of the "Guardian" safety feature of the Baxter Colleague smart infusion pumps and barriers to the usage for the purpose of increasing usage and reducing barriers.


Baxter Colleague infusion pumps have a "Guardian" feature that alerts users when pre-defined dosage limits for specific drugs are exceeded. Use of Guardian must be activated by the pump operator, which does not always happen. The WRHA regional policy for the Parenteral Drug Therapy Manual (which provides recommendations for IV administration of medications) mandates that the Guardian Software be used when the infused medication is contained within the software library. This project is a recurrent quality improvement initiative within the Critical Care and Medicine Programs in the WRHA to track usage patterns and to eliminate barriers for use.

Data Collection Method

When and how often to collect

Once a year there will be a three week audit period. There will be notification when a new collection cycle starts.

During the cycle, every data collector will randomly select two non-consecutive days each week when they will audit every Colleague Pump that is in use on their unit and record.

This data needs to be completed for all patients, not only those who are being sent, since the data is sent for all patients every time data is sent.

What are random, non-consecutive days

Two random non consecutive days means two or more days between pump audit days.


  • week 1: Monday, Thursday
  • week 2: Tuesday, Friday
  • week 3: Wednesday, Monday

What data is entered

On collection days, the following into the L_TmpV2:

  1. Project: SmartPump
  2. Item: drug type
  3. bool_var: Guardian Software used: YES or NO (on PDA check mark is YES, blank if NO).
  4. int_var: If Guardian is not used, obtain reason by asking the bedside nurse and enter reason code using the following comment key which should be printed out and kept with PDA as a reference:
    • 1. Reason unknown
    • 2. Nurse forgot to use Guardian
    • 3. Nurse not aware of policy to use Guardian
    • 4. Nurse not aware that drug is in the Guardian library
    • 5. Drug is missing from the Guardian Software libaray
    • 6. IV TKVO only
    • 7. Difficult to use Guardian software for a specific drug because of frequent bolus and med changes, e.g. antibiotics
    • 8. other
  5. comment field: if and only if you choose other you must type the actual reason into the comment field.
  6. the other fields are not used for this project

Data must be entered on the day it is collected

The PDA will automatically stamp the date and time of the the audit when you select the drug item. No need to manually enter the date and time when you audited the items. This means you have to actually enter the information into the PDA on the day collected

Collect, don't police

We are not policing the use of the Guardian feature, we simply gather anonymized information in order to allow management to assess where improvements and changes may be required. Names of bedside nurses are not tracked.

Date of Audits

  • March 3-25, 2008
  • September to October 2007

Legacy Data

This study should be run once per year and was started in 2006. Previous study periods are: <needs content>

Auto-date-stamping will only work if collected into the laptop directly (ie no paper step)

During the last cycle there were some problems with automatic date stamping at locations where data is not entered into the PDA at the time it is collected. What was the resolution of that? Ttenbergen 10:52, 22 August 2008 (CDT)

This would need to be resolved if we are going to do another round. Ttenbergen 14:15, 4 May 2011 (CDT)