@article{12047, keywords = {Healthcare quality improvement, Information technology, Medication safety, Near miss, Quality improvement}, author = {Kumiko O. Schnock and Patricia C. Dykes and Jennifer Albert and Deborah Ariosto and Rosemary Call and Caitlin Cameron and Diane L. Carroll and Adrienne G. Drucker and Linda Fang and Christine A. Garcia-Palm and Marla M. Husch and Ray R. Maddox and Nicole McDonald and Julie McGuire and Sally Rafie and Emilee Robertson and Deb Saine and Melinda Sawyer and Lisa P. Smith and Kristy Dixon Stinger and Timothy W. Vanderveen and Elizabeth Wade and Catherine S. Yoon and Stuart Lipsitz and David W. Bates}, title = {The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.}, abstract = {

INTRODUCTION: 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.

OBJECTIVES: We conducted a multisite study to investigate the types and frequency of intravenous medication errors associated with smart pumps in the USA.

METHODS: 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.

RESULTS: 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.

CONCLUSION: 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.

}, year = {2017}, journal = {BMJ Qual Saf}, volume = {26}, chapter = {131-140}, pages = {131-140}, month = {12/2017}, issn = {2044-5423}, doi = {10.1136/bmjqs-2015-004465}, language = {eng}, }