Qual Saf Health Care 19:i31-i35 doi:10.1136/qshc.2009.036384
  • Original research

Discrepancies between medication orders and infusion pump programming in a paediatric intensive care unit

  1. Matthew C Scanlon
  1. Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  1. Correspondence to Dr Rebecca A Russell, Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, PO Box 1997, MS 681, 9000 West Wisconsin Avenue, Milwaukee, WI 53201, USA; rarussel{at}
  • Accepted 24 February 2010


Background Errors and the incorrect use of medications are significant sources of risk and harm to children in US hospitals. The risk associated with medication infusions has led to recommendations for the adoption of technologies including computer order physician entry (CPOE) and ‘smart’ infusion pumps despite a paucity of evidence demonstrating the ability of these technologies to reduce harm to paediatric inpatients.

Objective To measure discrepancies between medication orders for infusions entered into a CPOE system and the medication being infused as measured by the programmed settings of the smart infusion pump within a paediatric intensive care unit.

Methods This study used a prospective, observational design in a 30-bed paediatric intensive care unit. Data were simultaneously collected from the medication orders in the CPOE system and the bedside smart infusion pumps by trained observers. Analysis consisted of a line-by-line comparison of order observation data with the pump observation data.

Conclusions Of 296 observations of medication infusions and 231 observations of intravenous fluid infusions, the frequency of discrepancies between orders entered and pumps programming ranged from 24.3% for observed medications to 42.4% for observed fluids. Anti-infectives (100%), concentrated electrolytes (46.7%) and anticoagulants (46.2%) were associated with greatest discrepancy between orders and programmed doses.


  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.