title: The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.
abstract: Intravenous medication errors persist despite the use of smart pumps. This suggests the need for a standardised methodology for measuring errors and highlights the importance of identifying issues around smart pump medication administration in order to improve patient safety.
  
  
  
  We conducted a multisite study to investigate the types and frequency of intravenous medication errors associated with smart pumps in the USA.
  
  
  
  10 hospitals of various sizes using smart pumps from a range of vendors participated. Data were collected using a prospective point prevalence approach to capture errors associated with medications administered via smart pumps and evaluate their potential for harm.
  
  
  
  A total of 478 patients and 1164 medication administrations were assessed. Of the observed infusions, 699 (60%) had one or more errors associated with their administration. Identified errors such as labelling errors and bypassing the smart pump and the drug library were predominantly associated with violations of hospital policy. These types of errors can result in medication errors. Errors were classified according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). 1 error of category E (0.1%), 4 of category D (0.3%) and 492 of category C (excluding deviations of hospital policy) (42%) were identified. Of these, unauthorised medication, bypassing the smart pump and wrong rate were the most frequent errors.
  
  
  
  We identified a high rate of error in the administration of intravenous medications despite the use of smart pumps. However, relatively few errors were potentially harmful. The results of this study will be useful in developing interventions to eliminate errors in the intravenous medication administration process.
authors.affiliation: Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Kumiko O
authors.initials: KO
authors.lastname: Schnock
authors.affiliation: Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Patricia C
authors.initials: PC
authors.lastname: Dykes
authors.affiliation: Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Albert
authors.affiliation: Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Deborah
authors.initials: D
authors.lastname: Ariosto
authors.affiliation: The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Rosemary
authors.initials: R
authors.lastname: Call
authors.affiliation: Department of Pharmacy, Maricopa Medical Center, Phoenix, Arizona, USA.
authors.forename: Caitlin
authors.initials: C
authors.lastname: Cameron
authors.affiliation: Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Diane L
authors.initials: DL
authors.lastname: Carroll
authors.affiliation: Partners eCare, Partners Healthcare, Boston, Massachusetts, USA.
authors.forename: Adrienne G
authors.initials: AG
authors.lastname: Drucker
authors.affiliation: Winchester Medical Center, Winchester, Virginia, USA.
authors.forename: Linda
authors.initials: L
authors.lastname: Fang
authors.affiliation: Central DuPage Hospital, Winfield, Illinois, USA.
authors.forename: Christine A
authors.initials: CA
authors.lastname: Garcia-Palm
authors.affiliation: Solutions Management and Business Development, BD, San Diego, California, USA.
authors.forename: Marla M
authors.initials: MM
authors.lastname: Husch
authors.affiliation: College of Pharmacy, University of Georgia, Savannah, Georgia, USA.
authors.forename: Ray R
authors.initials: RR
authors.lastname: Maddox
authors.affiliation: Department of Pharmacy, Maricopa Medical Center, Phoenix, Arizona, USA.
authors.forename: Nicole
authors.initials: N
authors.lastname: McDonald
authors.affiliation: Central DuPage Hospital, Winfield, Illinois, USA.
authors.forename: Julie
authors.initials: J
authors.lastname: McGuire
authors.affiliation: Department of Pharmacy, UC San Diego Health, San Diego, California, USA.
authors.forename: Sally
authors.initials: S
authors.lastname: Rafie
authors.affiliation: St Joseph's/Candler Health System, Savannah, Georgia, USA.
authors.forename: Emilee
authors.initials: E
authors.lastname: Robertson
authors.affiliation: Winchester Medical Center, Winchester, Virginia, USA.
authors.forename: Deb
authors.initials: D
authors.lastname: Saine
authors.affiliation: The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Melinda D
authors.initials: MD
authors.lastname: Sawyer
authors.affiliation: Department of Nursing, Western Connecticut Health Network, Danbury, Connecticut, USA.
authors.forename: Lisa P
authors.initials: LP
authors.lastname: Smith
authors.affiliation: Department of Nursing, Western Connecticut Health Network, Danbury, Connecticut, USA.
authors.forename: Kristy Dixon
authors.initials: KD
authors.lastname: Stinger
authors.affiliation: Solutions Management and Business Development, BD, San Diego, California, USA.
authors.forename: Timothy W
authors.initials: TW
authors.lastname: Vanderveen
authors.affiliation: Concord Hospital, Concord, New Hampshire, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Wade
authors.affiliation: Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Catherine S
authors.initials: CS
authors.lastname: Yoon
authors.affiliation: Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Stuart
authors.initials: S
authors.lastname: Lipsitz
authors.affiliation: Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Bates
mesh_terms: D006801:Humans; D007260:Infusion Pumps / Q000706:statistics & numerical data*; D007262:Infusions, Intravenous / Q000706:statistics & numerical data*; D008485:Medical Audit; D008508:Medication Errors / Q000517:prevention & control; D011446:Prospective Studies
keywords: Healthcare quality improvement; Information technology; Medication safety; Near miss; Quality improvement