Background
Patients in intensive care units (ICUs) frequently experience adverse drug events involving intravenous medications (IV-ADEs),
which are often preventable.
Objectives
To determine how frequently preventable IV-ADEs in ICUs match the safety features of a programmable infusion pump with safety
software (“smart pump”) and to suggest potential improvements in smart-pump design.
Design
Using retrospective medical-record review, we examined preventable IV-ADEs in ICUs before and after 2 hospitals replaced conventional
pumps with smart pumps. The smart pumps alerted users when programmed to deliver duplicate infusions or continuous-infusion
doses outside hospital-defined ranges.
Participants
4,604 critically ill adults at 1 academic and 1 nonacademic hospital.
Measurements
Preventable IV-ADEs matching smart-pump features and errors involved in preventable IV-ADEs.
Results
Of 100 preventable IV-ADEs identified, 4 involved errors matching smart-pump features. Two occurred before and 2 after smart-pump
implementation. Overall, 29% of preventable IV-ADEs involved overdoses; 37%, failures to monitor for potential problems; and
45%, failures to intervene when problems appeared. Error descriptions suggested that expanding smart pumps’ capabilities might
enable them to prevent more IV-ADEs.
Conclusion
The smart pumps we evaluated are unlikely to reduce preventable IV-ADEs in ICUs because they address only 4% of them. Expanding
smart-pump capabilities might prevent more IV-ADEs.
KEY WORDS drug therapy - medication error - prevention and control - infusion pump - decision making - computer-assisted - critical care