Connie Christian, MBA, CPHRM
KAMMCO, Facility Risk Management & Patient Safety Advisor

Over the last 15 years, the use of smart infusion pumps with dose error reduction software (DERS) for intravenous (IV) medications and fluids has proliferated across the continuum of care. Acute care facilities, ambulatory care, and long-term care settings have invested in smart infusion pumps due to their demonstrated safety potential. Through data collection of adverse event reporting, The Joint Commission and Institute for Safe Medication Practices (ISMP) have found medication errors are still occurring due to providers and staff misuse or lack of use of the DERS provided with their smart infusion pumps.
 
From The Joint Commission: “…many medication errors can be prevented through safe medication practices; however, sometimes these errors — including those involving “smart” infusion pumps — are caused by a combination of human and technical risk factors, including fatigue, distraction, and drug library overrides, deficiencies or misuse. For example, a health care professional working on a busy hospital floor mistakenly enters an incorrect flow rate into a smart infusion pump’s flow rate field while programming a medication infusion outside the drug library, resulting in a serious injury to the patient. 
 
Smart infusion pumps combine computer technology and drug libraries to limit the potential for dosing errors. Hospitalized patients commonly receive IV medications and fluids via smart infusion pumps, and errors involving the pumps occur each year. A study published in 2016 found that bypassing the smart infusion pump or the drug library accounted for about 10% of the total number of errors or policy violations relating to infusion administration. Smart pump errors can result in harm to patients that could be avoided by using built-in DERS.”
 
The ISMP and the Joint Commission adverse event data prompted the Joint Commission to issue Sentinel Alert No. 63: Optimizing smart infusion pump safety with DERS. The Joint Commission defines a sentinel event as a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are debilitating to both patients and health care providers. We encourage all KAMMCO insureds, regardless of accreditation status, to review the Sentinel Event Alert 63 and implement initiatives to reduce variation, reduce risk, and improve quality when using smart infusion pumps. 
 
Download and Review the Sentinel Event Alert 63
 
For more information on risk management or loss prevention and professional liability issues, contact Connie Christian at cchristian@KAMMCO.com.