Acute Care/Hospitalization

Automated piggyback infusion of intravenous drugs is neither simple nor safe

Many consider piggyback infusion of second intravenous drugs with "smart pumps" a simple task. However, a new study suggests that this practice is neither simple nor safe. Nurses typically use piggyback infusions to give patients a single-dose second intravenous drug when they are already receiving a maintenance infusion drug through an established intravenous access. This is usually done by hanging a second bag of medication and tubing above the first, with the second bag called a piggyback infusion. The nurse rigs the tubing for piggyback administration and programs the infusion device by entering data such as rate and volume of medication to be infused. Once the volume of the piggyback drug infuses, a process that can take several minutes to a few hours, the primary infusion resumes. Piggybacks allow for unattended drug infusion, which allows the nurse to leave the patient to tend to other duties.

To characterize piggyback medication infusion practice, University of Chicago researchers analyzed a U.S. Food and Drug Administration (FDA) database of device-related errors to find problems with automated piggybacks. They also observed 19 senior nursing staff performing piggybacks on different infusion pumps, and analyzed pump operation log files collected from 55 infusion pumps used in a major hospital.

The FDA database revealed 30 incidents of problems with piggyback infusions. Of these, 19 showed overinfusion of medication and 9 reported underinfusion, probably due to incorrect tubing setup. Log files showed that the alarm that alerts the nurse when the piggyback infusion is complete was not used. During programming tasks, experienced nurses struggled to complete the tubing, complex programming, and other requirements needed to complete the piggyback task in 20 (53 percent) of 38 scenarios. The researchers note that additional training cannot compensate for poor piggyback design. They suggest that clinicians be granted the autonomy to use alternative infusion strategies and be informed of the risk of allowing piggybacks to run unattended. The study was supported by the Agency for Healthcare Research and Quality (HS11816).

See "Time to get off this pig's back? The human factors aspects of the mismatch between device and real-world knowledge in the health care environment," by Mark E. Nunnally, M.D., and Yuval Bitan, Ph.D., in the September 2006 Journal of Patient Safety 2(3), pp. 124-131.

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