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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 4 of 4 Results
Schnock KO, Dykes PC, Albert J, et al. Drug Saf. 2018;41:591-602.
Intravenous medication administration errors related to smart pumps can compromise patient safety. Prior research has shown that such errors are common and often involve incorrect dosing and workarounds. Researchers describe the development and implementation of a multicomponent safety intervention bundle developed to reduce medication administration errors associated with smart pump use. Although both the overall error rate and medication error rate per 100 medication administrations decreased, the intervention did not lead to a reduction in the rate of potentially harmful errors. A past PSNet perspective discussed the use of smart pumps to improve safety.
Schnock KO, Dykes PC, Albert J, et al. BMJ Qual Saf. 2017;26:131-140.
Medication errors associated with intravenous smart pumps are a safety concern. Because errors are not always reported, the magnitude of this problem has been unknown. In this study, direct observation of nurses using smart pumps revealed that 60% of medication infusions involved one or more errors, but actual harm to patients was rare. The most common errors involved incorrect infusion rates and workarounds like bypassing the smart pump. These results accentuate a need for improvements in smart pump design to enhance safety and usability. A previous WebM&M commentary describes consequences of an incorrect medication infusion.
Husch M. Quality and Safety in Health Care. 2005;14.
Several FDA reports have generated concern over errors stemming from the use of intravenous (IV) pumps. This study observed the delivery of more than 425 IV medication administrations to determine the number, frequency, type, and severity of associated errors. Findings included an error rate of nearly 67%, with about 10% due to a programming mistake on the pump itself. The authors suggest that the use of "smart pumps" is only likely to prevent such errors if the pumps are better integrated into accompanying medication information systems, such as computerized prescriber order entry (CPOE).