Table 2

 Examples of errors with potential seriousness of “D” or greater and the potential impact of smart pump technology

NCC MERPType of errorMedication and dose infusing via IV pumpMedical record orderLikelihood of preventability with smart pump technology
DRate deviationNicardipine 25 mg/250 ml @ 15 mg/hStart nicardipine now. (No dose or titration protocol ordered)No
DRate deviationHydromorphone 0.2 mg/ml @ 1 mg every 30 minHydromorphone 2 mg every 30 min. (Verbal order not documented in medical record)No
EUnauthorized medicationHydromorphone 1 mg/ml at 2 mg every 15 min prn(No new order written upon transfer to the ICU)No
EUnauthorized medicationAmiodarone 0.5 mg/minOrder written 5 days prior: Amiodarone 1 mg/min×6 h then 0.5 mg/min×18 h. No continuing orders written past the first 24 hNo
ERate deviationHydromorphone 1 mg/ml @ 0.5 mg every 15 min prnHydromorphone 0.2 mg/ml @ 1 mg every 15 minutes. (This discontinued order was erroneously copied upon transfer to ICU)No
FRate deviationHeparin 200 units/h (2 ml/h)Heparin 1300 units/h for venous thromboembolism.(Pump inadvertently programmed for incorrect dose)Yes
FRate deviationDopamine 800 mg/250 ml @ 2 μg/kg/hDopamine 200 mg/250 ml @ 15 ml/h (2 μg/kg/h)(Infusing rate 4× higher than ordered dose due to wrong concentration dispensed from pharmacy and programmed into pump)No
FRate deviation0.9 normal saline at 20 ml/h0.9 normal saline at 250 ml/h. Patient severely volume depleted. (Programming mistake)No