title: Smart pump alerts: all that glitters is not gold.
abstract: BACKGROUND
  The implementation of smart pump technology can reduce the incidence of errors in the administration of intravenous drugs. This approach involves developing drug libraries for specific units and setting hard and soft limits for each drug. If a programming error occurs and these limits are exceeded, an alarm sounds and the infusion can be blocked. A detailed analysis of these alarms is essential in order not to bias the results in favor of a positive impact of this technology.
  
  
  OBJECTIVE
  To evaluate the results of the first analysis of the use of smart infusion pumps and to assess the significance and practical implications of the alarms sounded.
  
  
  METHODS
  The study was performed by a multidisciplinary team that consisted of a clinical pharmacist, a pediatrician from the pediatric intensive care unit (PICU), and the chief nurse of the unit. A library of 108 drugs was developed over a 7-month period and introduced into 40 syringe pumps and 12 volumetric pumps (Alaris(®) with Plus software) before being applied in 6 of the 11 beds in the PICU. After four month's use, data were analyzed using the Guardrails(®) CQI v4.1 Event Reporter program.
  
  
  RESULTS
  Following the first four months of implementation, compliance with the drug library was 87%. By analyzing the alerts triggered, we were able to detect problems such as the need to increase user training, readjust limits that did not correspond to clinical practice, correct errors in the editing of the drug library and including a training profile.
  
  
  CONCLUSIONS
  It is difficult to obtain accurate data on the true impact of this technology in the early stages of its implementation. This preliminary analysis allowed us to identify improvement measures to distinguish, in future evaluations, the alarms triggered by a real programming error from those caused by incorrect use.
authors.affiliation: Pharmacy Service, Hospital General Universitario Gregorio Marañón, Spain. smanrique.hgugm@salud.madrid.org
authors.forename: Silvia
authors.initials: S
authors.lastname: Manrique-Rodríguez
authors.forename: Amelia
authors.initials: A
authors.lastname: Sánchez-Galindo
authors.forename: Cecilia M
authors.initials: CM
authors.lastname: Fernández-Llamazares
authors.forename: Jesús
authors.initials: J
authors.lastname: López-Herce
authors.forename: Lara
authors.initials: L
authors.lastname: Echarri-Martínez
authors.forename: Vicente
authors.initials: V
authors.lastname: Escudero-Vilaplana
authors.forename: María
authors.initials: M
authors.lastname: Sanjuro-Sáez
authors.forename: Angel
authors.initials: A
authors.lastname: Carrillo-Álvarez
mesh_terms: D002648:Child; D020000:Decision Support Systems, Clinical; D004358:Drug Therapy / Q000295:instrumentation*; D004360:Drug Therapy, Computer-Assisted; D004869:Equipment Safety; D006801:Humans; D007260:Infusion Pumps; D007262:Infusions, Intravenous / Q000295:instrumentation*; D015278:Intensive Care Units, Pediatric; D008508:Medication Errors / Q000517:prevention & control*; D012308:Risk Management; D012984:Software