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PSNet: Patient Safety Network
Journal Article
Review

Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies.

Kirkendall ES, Timmons K, Huth H, et al. Drug Saf. 2020;Epub Aug 17.

This systematic review catalogued and mapped the types of human errors related to smart pumps and associated error-prevention strategies. Error categories included (1) undocumented errors, (2) drug library errors, (3) programming errors, (4) administration errors, and (5) ancillary equipment errors. The authors mapped these errors to existing, standardized medication error classification and found that some errors (e.g., drug library errors) are introduced by the implementation of smart pump technology and some may be the result of workarounds. A range of prevention strategies were identified and mapped to the error types. These findings can serve as a toolkit for clinical use and development of best practices.