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


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.

  • Medications
  • infusion pumps
  • computer order entry
  • pediatrics
  • risk
  • healthcare quality improvement
  • human factors
  • medication error
  • medication safety
  • patient safety

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