Case number | NCC MERP index | Type of error | Medication and dose infusing via intravenous pump | Medical record order | Judged to be preventable* |
---|---|---|---|---|---|
1 | E | Delay | D5W not infusing was observed at 11:43 on index date, patient was hypoglycaemic, fluid was ordered, hung and programmed but not started. Patient’s blood glucose continued to trend down | D5W due at 9:06 on index date | Yes (only with closed loop smart pump) |
2 | D | Delay | Norepinephrine 8 mg/500 mL, 7 mcg/min, 26.3 mL/h (observed at 10:06 on index date) | Norepinephrine 8 mg/500 mL, 7 mcg/min, 26.3 mL/h. Systolic blood pressure was below 100 mm Hg at 3:45 but drip not started until 7:00 | Yes (only with closed loop smart pump) |
3 | D | Wrong rate | Magnesium sulfate 1 g/100 mL, 100 mL/h | Magnesium sulfate 1 g/100 mL, 200 mL/h | Yes (only with closed loop smart pump) |
4 | D | Wrong rate | Norepinephrine 32 mg/250 mL, 20 mcg/min, 9.4 mL/h. Ordered rate was changed on eMAR | Norepinephrine 32 mg/250 mL, 6 mcg/min, 2.8 mL/h | Yes (only with closed loop smart pump) |
5 | D | Omission | Had not been hung at 16:12 | Piperacillin/tazobactam 3.375 g/100 mL (0.034 g/mL) due at 12:00 | Yes (only with closed loop smart pump) |
*Judged to be preventable was based on the assumption that smart pump technology (with/without closed loop) could have intercepted these errors (judgements made by the research team). All errors rated D or greater were reviewed.
D5W, dextrose 5% in water; eMAR, electronic medication administration record; NCC MERP, National Coordinating Council for Medication Error Reporting and Prevention.