Executive Summary

Virtua Health (Marlton, NJ) was named a finalist for the 3rd Health Devices Achievement Award in September 2008 for its project to increase the use of the drug libraries on its smart infusion pumps.

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As patient safety continues to rank at the forefront of hospital concerns, more and more automation has been added to formerly manual processes. For example, a generation of "smart" infusion pumps has been developed to minimize adverse drug events resulting from pump programming errors committed by clinicians. Using drug libraries that allow programmed doses to be checked against preset limits specific to a drug and to a clinical application or location, these pumps alert clinicians to doses that exceed those limits.

To reduce programming mistakes, Virtua Health (Marlton, NJ) acquired about 900 smart pumps for its facilities. Initially, however, the pumps' drug libraries were being used only about 10% of the time. A year later, even after additional training, utilization remained low—about 25%. An interdisciplinary Six Sigma team was assembled to look into the issue.

The team first analyzed current pump practices by organizing focus groups, administering surveys, collecting data, and conducting interviews. Having amassed the necessary information, the team categorized the reasons for poor compliance, identifying them as having high, medium, or low impact on utilization rates. It then focused on those high-impact causes that were preventable: cumbersome pump programming, the lack of a set process for requesting changes to the drug library content, and inadequate staff understanding of the value of the drug libraries and how to use them.

Having identified the main problems, the team began developing solutions. It worked with the pump manufacturer to streamline access to the drug library. It implemented a staff education program to stress the importance of the drug libraries and better educate clinicians about their use. And it developed better communication with users about how to have the drug libraries updated to meet the needs of specific care areas.

Thanks to this initiative, use of the drug libraries increased from 25% to 55% in the space of a year and recently reached 72%. Staff are now more aware of, and comfortable with, the safety software. And the foundation has been laid for implementing other smart software in the future.

This project earned Virtua Health recognition as a finalist for the 3rd Health Devices Achievement Award, issued by ECRI Institute in 2008 to honor excellence in health technology management. Learn about the other submissions that achieved recognition.




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Infusion Therapy; Medication/Drug Safety; Pharmacy


Ambulatory Surgery Center; Emergency Department; Hospital Inpatient; Hospital Outpatient

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Biomedical/Clinical Engineer; Nurse; Pharmacist; Risk Manager

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