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The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study
  1. Kumiko O Schnock1,
  2. Patricia C Dykes1,
  3. Jennifer Albert2,
  4. Deborah Ariosto3,
  5. Rosemary Call4,
  6. Caitlin Cameron5,
  7. Diane L Carroll2,
  8. Adrienne G Drucker6,
  9. Linda Fang7,
  10. Christine A Garcia-Palm8,
  11. Marla M Husch9,
  12. Ray R Maddox10,
  13. Nicole McDonald5,
  14. Julie McGuire8,
  15. Sally Rafie11,
  16. Emilee Robertson12,
  17. Deb Saine7,
  18. Melinda D Sawyer4,
  19. Lisa P Smith13,
  20. Kristy Dixon Stinger13,
  21. Timothy W Vanderveen9,
  22. Elizabeth Wade14,
  23. Catherine S Yoon1,
  24. Stuart Lipsitz1,
  25. David W Bates1
  1. 1Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
  2. 2Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
  3. 3Vanderbilt University Medical Center, Nashville, Tennessee, USA
  4. 4The Johns Hopkins Hospital, Baltimore, Maryland, USA
  5. 5Department of Pharmacy, Maricopa Medical Center, Phoenix, Arizona, USA
  6. 6Partners eCare, Partners Healthcare, Boston, Massachusetts, USA
  7. 7Winchester Medical Center, Winchester, Virginia, USA
  8. 8Central DuPage Hospital, Winfield, Illinois, USA
  9. 9Solutions Management and Business Development, BD, San Diego, California, USA
  10. 10College of Pharmacy, University of Georgia, Savannah, Georgia, USA
  11. 11Department of Pharmacy, UC San Diego Health, San Diego, California, USA
  12. 12St Joseph's/Candler Health System, Savannah, Georgia, USA
  13. 13Department of Nursing, Western Connecticut Health Network, Danbury, Connecticut, USA
  14. 14Concord Hospital, Concord, New Hampshire, USA
  1. Correspondence to Dr Kumiko O Schnock, Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, OBC-3, Boston, MA 02120-1613, USA; kschnock{at}


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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