Introduction Intravenous medication errors persist despite the use of smart pumps. This suggests the need for a standardised methodology for measuring errors and highlights the importance of identifying issues around smart pump medication administration in order to improve patient safety.
Objectives We conducted a multisite study to investigate the types and frequency of intravenous medication errors associated with smart pumps in the USA.
Methods 10 hospitals of various sizes using smart pumps from a range of vendors participated. Data were collected using a prospective point prevalence approach to capture errors associated with medications administered via smart pumps and evaluate their potential for harm.
Results A total of 478 patients and 1164 medication administrations were assessed. Of the observed infusions, 699 (60%) had one or more errors associated with their administration. Identified errors such as labelling errors and bypassing the smart pump and the drug library were predominantly associated with violations of hospital policy. These types of errors can result in medication errors. Errors were classified according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). 1 error of category E (0.1%), 4 of category D (0.3%) and 492 of category C (excluding deviations of hospital policy) (42%) were identified. Of these, unauthorised medication, bypassing the smart pump and wrong rate were the most frequent errors.
Conclusion We identified a high rate of error in the administration of intravenous medications despite the use of smart pumps. However, relatively few errors were potentially harmful. The results of this study will be useful in developing interventions to eliminate errors in the intravenous medication administration process.
- Medication safety
- Quality improvement
- Near miss
- Healthcare quality improvement
- Information technology
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Contributors KOC, PCD, CSY, SL and DWB: contributed to conception and design, analysis and interpretation of the data and results, drafting and writing the article, revising it critically for important intellectual content and final approval of the version to be published. JA, DA, RC, CC, DLC, AD, LF, CAG-P, MMH, RRM, NM, JM, SR, ER, DS, MDS, LPS, KDS and EW: contributed to supervision of the data collection at each site, developed hypotheses, analysis and interpretation of the data and results, as well as drafting and writing the article, revising it critically for important intellectual content and final approval of the version to be published. TWV: contributed to conception and revising the paper critically for important intellectual content.
Funding Carefusion Foundation; Association for the Advancement of Medical Instrumentation (AAMI).
Competing interests None declared.
Ethics approval Partners Healthcare Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.
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