Majority of IV Infusion Errors Linked to Clinical Practice

Data were collected using a prospective point prevalence approach to capture errors associated with 1,164 smart pump IV administrations to 478 patients, with concurrent evaluation of their potential for harm.

The results showed that of the observed infusions, 699 (60%) had one or more errors associated with their administration, but relatively few of these errors were potentially harmful. The most predominant errors were associated with violations of hospital infusion policy, and included the administration of unauthorized medications, bypassing the smart pump, wrong rate of infusion, labelling errors, and bypassing the integrated drug library.

The researchers suggested that most of these mistakes could be prevented if closed-loop systems, in which the smart pumps are automatically programed with a medication order using the patient’s electronic health record (EHR), were implemented as policy. This would necessitate that a nurse verify the information on the smart pump and accept the data, including drug name, infusion rate, volume, and concentration, before the infusion could begin. The study was published on February 23, 2016, in BMJ Quality & Safety.

“Since these errors are not directly related to the use of smart pumps, these finding suggest that smart pump technology alone cannot fully prevent errors associated with intravenous infusions,” concluded lead author Kumiko Schnock, MD, of Brigham and Women's Hospital, and colleagues. “The results of this study will be useful in developing interventions to eliminate errors in the intravenous medication administration process.”

Smart infusion pumps were developed to reduce adverse drug events and medication administration errors through built-in safety features, such as built-in drug libraries and dose error reduction systems. According to a national survey conducted by the American Society of Health-System Pharmacists (Bethesda, MD, USA), in 2012 77% of hospitals in the United States use smart pump technology.

Related Links:
Brigham and Women's Hospital
Concord Hospital
American Society of Health-System Pharmacists