Examples of errors with potential seriousness of “D” or greater and the potential impact of smart pump technology
| NCC MERP | Type of error | Medication and dose infusing via IV pump | Medical record order | Likelihood of preventability with smart pump technology |
|---|---|---|---|---|
| D | Rate deviation | Nicardipine 25 mg/250 ml @ 15 mg/h | Start nicardipine now. (No dose or titration protocol ordered) | No |
| D | Rate deviation | Hydromorphone 0.2 mg/ml @ 1 mg every 30 min | Hydromorphone 2 mg every 30 min. (Verbal order not documented in medical record) | No |
| E | Unauthorized medication | Hydromorphone 1 mg/ml at 2 mg every 15 min prn | (No new order written upon transfer to the ICU) | No |
| E | Unauthorized medication | Amiodarone 0.5 mg/min | Order 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 h | No |
| E | Rate deviation | Hydromorphone 1 mg/ml @ 0.5 mg every 15 min prn | Hydromorphone 0.2 mg/ml @ 1 mg every 15 minutes. (This discontinued order was erroneously copied upon transfer to ICU) | No |
| F | Rate deviation | Heparin 200 units/h (2 ml/h) | Heparin 1300 units/h for venous thromboembolism.(Pump inadvertently programmed for incorrect dose) | Yes |
| F | Rate deviation | Dopamine 800 mg/250 ml @ 2 μg/kg/h | Dopamine 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 |
| F | Rate deviation | 0.9 normal saline at 20 ml/h | 0.9 normal saline at 250 ml/h. Patient severely volume depleted. (Programming mistake) | No |