Sentinel Event Alert 63: Optimizing smart infusion pump safety with DERS

Many medication errors can be prevented through safe medication practices; however, sometimes these errors — including those involving “smart” infusion pumps — are caused by a combination of human and technical risk factors, including fatigue, distraction, and drug library overrides, deficiencies or misuse. For example, a health care professional working on a busy hospital floor mistakenly enters an incorrect flow rate into a smart infusion pump’s flow rate field while programming a medication infusion outside the drug library, resulting in a serious injury to the patient.

Smart infusion pumps combine computer technology and drug libraries to limit the potential for dosing errors. Hospitalized patients commonly receive intravenous (IV) medications and fluids via smart infusion pumps, and errors involving the pumps occur each year. A study published in 2016 found that bypassing the smart infusion pump or the drug library accounted for about 10% of the total number of errors or policy violations relating to infusion administration. Smart pump errors can result in harm to patients that could be avoided by using built-in dose error reduction software (DERS).