Development of an "infusion pump safety score".

Rick Carlson; Beth Johnson; Richard H Ensign

Commentary

Development of an "infusion pump safety score".

May 20, 2015

Carlson R, Johnson B, Ensign RH. Am J Health Syst Pharm. 2015;72(10):777-9.

View more articles from the same authors.

Although infusion pumps improve the safety of medication delivery, they can also contribute to alert fatigue and decrease individualized patient care. This commentary describes how a large health care system developed a scoring system to analyze the appropriateness of alerts recorded by infusion pumps and customize concentrations of the drugs delivered.

PubMed citation

Available at

Related Resources From the Same Author(s)

Can patient safety be measured by surveys of patient experiences?

April 30, 2008

What went right: lessons for the intensivist from the crew of US Airways Flight 1549.

September 23, 2009

Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality-improvement research.

January 28, 2009

Intraoperative handoffs among anesthesia providers increase the incidence of documentation errors for controlled drugs.

August 9, 2017

Cleveland Clinic cases highlight flaws in safety oversight.

June 25, 2014

Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record.

July 1, 2009

A survey of factors affecting clinician acceptance of clinical decision support.

February 22, 2006

Trends in the prevalence of intraoperative adverse events at two academic hospitals after implementation of a mandatory reporting system.

April 25, 2018

Computerized provider order entry adoption: implications for clinical workflow.

December 10, 2008

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration.

October 15, 2008

Assessing the anticipated consequences of computer-based provider order entry at three community hospitals using an open-ended, semi-structured survey instrument.

July 16, 2008

Types of unintended consequences related to computerized provider order entry.

September 20, 2006

Engaging the patient and family in the surgical safety process utilizing SafeStart.

August 28, 2019

The extent and importance of unintended consequences related to computerized provider order entry.

May 16, 2007

The problem with…using stories as a source of evidence and learning.

March 9, 2022

Anatomy of an incident disclosure: the importance of dialogue.

October 3, 2012

Differences in safety climate among hospital anesthesia departments and the effect of a realistic simulation-based training program.

February 20, 2008

Quality-monitoring program for bar-code–assisted medication administration.

June 17, 2009

Using an advanced practice nursing model for a rapid response team.

December 3, 2008

Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients.

April 22, 2009

How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous thromboembolism?

January 13, 2010

Medication reconciliation for reducing drug-discrepancy adverse events.

November 8, 2006

Patient-centered prescription opioid tapering in community outpatients with chronic pain.

March 7, 2018

Injury and death associated with incidents reported to the Patient Safety Net.

September 23, 2009

Patients' and families' perspectives of patient safety at the end of life: a video-reflexive ethnography study.

March 30, 2016

Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study.

October 22, 2014

Institution of just culture physician peer review in an academic medical center.

October 13, 2021

Patient safety in nursing practice.

July 20, 2005

Implementation of standardized dosing units for I.V. medications.

January 21, 2015

Narrativizing errors of care: critical incident reporting in clinical practice.

July 20, 2005

Improving shared situation awareness for high-risk therapies in hospitalized children.

January 19, 2022

Why empathy may be the best risk management strategy.

March 11, 2015

Finding the patient in patient safety.

February 13, 2013

What do patients and relatives know about problems and failures in care?

January 18, 2012

What prevents incident disclosure, and what can be done to promote it?

August 31, 2011

Clinical relevance of and risk factors associated with medication administration time errors.

July 10, 2013

Practising open disclosure: clinical incident communication and systems improvement.

January 7, 2009

A culture of civility: positively impacting practice and patient safety.

April 25, 2018

Using multidisciplinary rounds to improve patient safety through venous thromboembolism prevention awareness.

September 9, 2015

Maximizing smart pump technology to enhance patient safety.

July 29, 2015

Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward.

September 9, 2009

Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.

March 17, 2010

A new structure of attention? Open disclosure of adverse events to patients and their families.

June 24, 2009

Theoretical approaches for investigating patient safety.

June 1, 2005

The contribution of nurses to incident disclosure: a narrative review.

August 28, 2013

Health care professionals' views of implementing a policy of open disclosure of errors.

January 14, 2009

Disclosing clinical adverse events to patients: can practice inform policy?

October 21, 2009

The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support.

June 16, 2010

Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme.

December 20, 2006

Patient safety informatics: meeting the challenges of emerging digital health.

July 20, 2022

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: a prioritisation nominal group technique.

August 16, 2023

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

August 18, 2010

Psychiatry morbidity and mortality rounds: implementation and impact.

November 11, 2009

Limiting nurse overtime, and promoting other good working conditions, influences patient safety.

April 9, 2008

Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation.

November 18, 2020

Multiple accountabilities in incident reporting and management.

August 4, 2010

Effectiveness of a computerized system for intravenous heparin administration: using information technology to improve patient care and patient safety.

May 11, 2005

The increased incidence of anesthetic adverse events in late afternoon surgeries.

July 30, 2008

Preventing central line–associated bloodstream infections in the intensive care unit: application of high-reliability principles.

December 19, 2018

A qualitative study of patient involvement in medicines management after hospital discharge: an under-recognised source of systems resilience.

November 29, 2017

Afraid in the hospital: parental concern for errors during a child's hospitalization.

August 19, 2009

Implementing a warm handoff between hospital and skilled nursing facility clinicians.

September 18, 2019

Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.

February 2, 2011

Medication, allergy, and adverse drug event discrepancies in ambulatory care.

March 26, 2008

The missing evidence: a systematic review of patients' experiences of adverse events in health care.

October 28, 2015

Costs of intravenous adverse drug events in academic and nonacademic intensive care units.

January 16, 2008

Creative education for rapid response team implementation.

March 11, 2009

Patients' reports of adverse events: a data linkage study of Australian adults aged 45 years and over.

September 6, 2017

Healthcare worker serious safety events: applying concepts from patient safety to improve healthcare worker safety.

August 4, 2021

Patients' and family members' experiences of open disclosure following adverse events.

October 15, 2008

Closing the gap and raising the bar: assessing board competency in quality and safety.

May 10, 2017

The mixed blessings of smart infusion devices and health care IT.

October 8, 2014

Patient safety in nursing practice.

October 3, 2007

Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative.

May 15, 2019

Enhancing pediatric perioperative patient safety.

November 29, 2017

The application of Aronson's taxonomy to medication errors in nursing.

October 20, 2010

A model for building a standardized hand-off protocol.

November 8, 2006

Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19.

October 21, 2020

Integrating patient safety into health professionals' curricula: a qualitative study of medical, nursing and pharmacy faculty perspectives.

February 19, 2014

Identifying boundary spanning reporter roles in patient safety events.

August 24, 2022

Who killed patient safety?

July 20, 2022

Understanding interdisciplinary health care teams: using simulation design processes from the Air Carrier Advanced Qualification Program to identify and train critical teamwork skills.

December 9, 2009

Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.

October 30, 2013

Errors in after-hours phone consultations: a simulation study.

March 5, 2014

A multicenter collaborative approach to reducing pediatric codes outside the ICU.

March 7, 2012

The Daily Plan: including patients for safety's sake.

April 11, 2012

Disclosing errors to patients: perspectives of registered nurses.

January 14, 2009

Processes for effective communication in primary care.

May 4, 2005

Nurses discuss bedside handover and using written handover sheets.

February 13, 2013

Patient safety: break the silence.

May 9, 2012

A plan for achieving significant improvement in patient safety.

April 4, 2007

Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence.

April 12, 2023

Burnout mediates the association between depression and patient safety perceptions: a cross-sectional study in hospital nurses.

April 26, 2017

Reasons for after-hours calls by hospital floor nurses to on-call physicians.

May 30, 2007

Improving RCA performance: the Cornerstone Award and the power of positive reinforcement.

August 17, 2011

Handoff practices in undergraduate medical education.

March 12, 2014

The disclosure dilemma—large-scale adverse events.

September 8, 2010

Adoption of technology to improve medication safety: perspectives of pharmacy directors.

January 10, 2007

The views and experiences of patients and health-care professionals on the disclosure of adverse events: a systematic review and qualitative meta-ethnographic synthesis.

April 8, 2020

The influence of bullying on nursing practice errors: a systematic review.

March 4, 2020

Related Resources

Interview

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

An implementation science approach to promote optimal implementation, adoption, use, and spread of continuous clinical monitoring system technology.

January 27, 2021

The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.

July 29, 2020

Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data.

July 22, 2020

Stakeholder perceptions of smart infusion pumps and drug library updates: a multisite, interdisciplinary study.

September 25, 2019

Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.

July 10, 2019

Solving alarm fatigue with smartphone technology.

January 23, 2019

Managing alarm systems for quality and safety in the hospital setting.

November 14, 2018

Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse drug events in the intensive care unit and general ward.

August 1, 2018

Development of a standardized, citywide process for managing smart-pump drug libraries.

August 1, 2018

Survey results: smart pump data analytics pump metrics that should be monitored to improve safety.

July 25, 2018

Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.

June 20, 2018

Errors and discrepancies in the administration of intravenous infusions: a mixed methods multihospital observational study.

June 6, 2018

Safer healthcare at home: detecting, correcting and learning from incidents involving infusion devices.

April 18, 2018

Smart pumps in practice: survey results reveal widespread use, but optimization is challenging.

April 18, 2018

Strategies to reduce patient harm from infusion-associated medication errors: a scoping review.

January 31, 2018

Improving infusion pump safety through usability testing.

May 31, 2017

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

May 24, 2017

Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital.

April 19, 2017

How redesigning the abrasive alarms of hospital soundscapes can save lives.

April 12, 2017

Infusion medication error reduction by two-person verification: a quality improvement initiative.

February 1, 2017

Changing smart pump vendors: lessons learned.

December 14, 2016

Alarm fatigue: use of an evidence-based alarm management strategy.

September 14, 2016

Patient safety implications of electronic alerts and alarms of maternal–fetal status during labor.

August 31, 2016

Alarm management: promoting safety and establishing guidelines.

May 25, 2016

Perspective

Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue

May 1, 2016

Interview

In Conversation With... Barbara Drew, RN, PhD

May 1, 2016

Scandal as a sentinel event—recognizing hidden cost–quality trade-offs.

April 6, 2016

See More About The Topic

Hospitals

Health Care Executives and Administrators

Medicine

Infusion Pumps

Epidemiology of Errors and Adverse Events

Development of an "infusion pump safety score".

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Development of an "infusion pump safety score".

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site