Table 4

Examples of errors with potential seriousness of Harm Index D or greater and judged to be preventable

Case numberNCC MERP indexType of errorMedication and dose infusing via intravenous pumpMedical record orderJudged to be preventable*
1EDelayD5W 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 downD5W due at 9:06 on index dateYes (only with closed loop smart pump)
2DDelayNorepinephrine 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 7:00Yes (only with closed loop smart pump)
3DWrong rateMagnesium sulfate 1 g/100 mL, 100 mL/hMagnesium sulfate 1 g/100 mL, 200 mL/hYes (only with closed loop smart pump)
4DWrong rateNorepinephrine 32 mg/250 mL, 20 mcg/min, 9.4 mL/h. Ordered rate was changed on eMARNorepinephrine 32 mg/250 mL, 6 mcg/min, 2.8 mL/hYes (only with closed loop smart pump)
5DOmissionHad not been hung at 16:12Piperacillin/tazobactam 3.375 g/100 mL (0.034 g/mL) due at 12:00Yes (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.