Look-alike medications can cause confusion and contribute to medication administration errors. This scoping review including 18 articles identified several risk reduction strategies to mitigate look-alike medication errors in perioperative settings, such as improved labelling and standardization of storage. The authors note that further research is needed to assess the effectiveness of technology-based solutions, such as automated dispensing cabinets.

To maximize safety benefits of smart infusion pumps, drug libraries between the pump, electronic health record (EHR) and pharmacy must be standardized. This article describes the proactive standardization between drug libraries for continuous infusions, including medication names, concentrations, and pump rates. 82 updates were required across the three libraries.

The safety culture of an operating room is known to affect teamwork and patient outcome. This article discusses the unique characteristics of robotic-assisted surgical practice and approaches teams and organizations can take to enhance communication that supports a safe care culture.

High-alert medications can cause serious patient harm if administered incorrectly. This article describes a quality improvement project to reduce medication errors involving high-alert sedative and analgesic medications in the intensive care unit (ICU) through use of protocolized and centralized smart intravenous infusion pump technology. Use of the protocolized software led to the interception of nearly 400 infusion-related programming errors.

Insulin pump malfunctions are a known contributor to adverse events. This study used six months of adverse events reported to the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database to identify root causes and consequences of errors associated with insulin pump malfunctions. Hyper- and hypoglycemia were the most common clinical consequences of the malfunction; only half of the reports identified a potential root cause.

Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.

Smart pump software can improve medication safety but can also introduce patient safety hazards, such as alert fatigue. In this study, dose error reduction software (DERS) was implemented across two large UK National Health Service (NHS) institutes for one year. Findings indicate that compliance with DERS was 45%, but across one year of implementation, severe harm or death was avoided in up to 110 patients.

When hospitals began to fill up with COVID-19 patients, new strategies had to be developed and implemented quickly to reduce the spread of the virus. This article describes one strategy implemented by a New York hospital: relocating smart intravenous (iv) infusion pumps outside of patient rooms. Challenges, facilitators, and lessons learned are discussed.

Medication errors threaten patient safety and can result in adverse outcomes. This systematic review identified seven types of nursing interventions used to reduce medication administration errors in pediatric and neonatal patients: education programs, medication information services, clinical pharmacist involvement, double checking, barriers to reduce interruptions during drug calculation and preparation, use of smart pumps, and improvement strategies (e.g., checklists, process or policy changes). Meta-analysis pooling results from various types of interventions demonstrated a 64% reduction in medication administration errors.

Smart pumps can improve medication safety, but barriers such as workarounds and alert fatigue can limit their effectiveness. After implementing smart pumps with an electronic health record (EHR) system, this community hospital saw increased drug library compliance and fewer infusions generating alerts.

Interoperability of smart pumps and electronic health record (EHR) systems can improve clinical data accuracy. This study evaluated the utility of harmonizing EHR data and smart pump records (SPRs) in detecting medication administration errors in one neonatal intensive care unit (NICU). The authors found that compared with medication administration records, dosing discrepancies were more commonly detectable using integrated SPRs, which suggests that this approach may be a more reliable data source for medication error detection.

Smart pumps are considered a valuable method to improve medication safety. This study used smart pump medication logs and reporting software to identify cancelled infusions and resolutions of infusions alerts to characterize near-miss infusion pump errors. The study identified a high number of lookalike-soundalike near-miss errors. Analyses indicate that incorrect medication and wrong dose selections account for approximately 22% of all cancelled infusions.

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.  

Smart infusion pumps store drug safety information, but this data must be periodically updated. This study demonstrated significant delays in updating the drug information for smart infusion pumps. These delays resulted in failure to alert for two high-risk medication cases, but neither case led to patient harm.

Pharmacy robots are now commonly used in hospitals for dispensing medications. Conducted at a Spanish hospital, this study found that use of pharmacy robots reduced medication dispensing errors and improved staff efficiency. The role of a pharmacy robot in a serious medication error is explored in a book that examined the effects of technological change on the health care system.