Running head: MEDICATION ERRORS USING INFUSION PUMPS

Medication Errors Using Infusion Pumps

Alexandra Bair
University of South Florida, College of Nursing

Medication Errors Using Infusion Pumps

Medication errors are the eighth leading cause of patient death in the United States and
have the potential of occurring in any healthcare setting (Mason, Roberts-Turner, Amendola, Sill,
& Hinds, 2014). Among medication errors, intravenous medication errors cause serious
problems due to the direct administration of the drugs into the blood stream and the complete
bioavailability of the drugs. Many regulations and standards have been put in place in healthcare
fields to prevent and decrease costly medication errors. Smart infusion pumps are an example of
the evolution of technology within the healthcare industry. These smart pumps are intended to
provide a line of defense at the patients bedside to decrease errors with intravenous medications
with the incorporation of software programs known as dose error reductions systems (DERS)

and drug libraries (Ohashi, Dalleur, Dykes, & Bates, 2014). This paper discusses a common type
of infusion pump medication error, the potential interventions for avoiding the medication error,
and a medication error I fear I may commit in clinical practice.

An Error in Infusion Pumps

In a case study, a forty year old male presented with a diagnosis of community-acquired
pneumonia and respiratory failure to the hospital emergency room. The patient required
intubation and ventilation due to inability to maintain oxygen saturation on one hundred percent
high flow oxygen via facemask within four hours. The blood pressure dropped after intubation
and a standard of norepinephrine infusion of 12 milligrams (mg) in 250 milliliters (mL) was
started at 10 micrograms (mcg) per minute and the patient was transferred to the intensive care
unit (ICU). An ICU nurse took over and continued to titrate the norepinephrine between 3 and
10 mcg per minute to maintain mean arterial pressure (MAP) (Ibey, Ciarniello, & Gorelik, 2015).
A little over an hour later, the physiologic monitor alarms sounded notifying the patients blood
pressure was 325/190 millimeters of mercury (mmHg) by arterial line and the heart rate was 90
beats per minute with an irregular rhythm. The norepinephrine infusion pump had been running
a continuous rate of 999 mL per hour. Reviewing the logged events defined by the keystroke on
the pump, the pump was navigated to the loading dose rate and set but the previous volume to be
infused was not adjusted (Ibey et al., 2015). The incorrect infusion rate was set in the pump due
to an oversight by the nurse.
The error occurred with the incorrect input of infusion rate into the infusion pump. The
fault was with the outdated software of the infusion pump and the nurses failure to catch the

MEDICATION ERRORS USING INFUSION PUMPS

error upon input of the infusion rate. Miscalculations of infusion rate and mistakes in rate input
are common errors which happen with infusion pumps in the healthcare setting.

Suggestions for Improvement and Interventions

Interventions have already been put into place to prevent errors discussed in the previous
section. The smart infusion pump software needs regular updates and upgrades to prevent
similar issues from occurring. Biomedical engineering (BME) targeted outdated software pumps
and upgraded the software accordingly. BME further explored and suggested disabling the
loading dose infusion mode on the Alaris pumps to ensure there would not be a repeat event
(Ibey et al., 2015).
Other improvements that should be included are developing standardized drug libraries
with automated updates to the pumps, along with upgrading the pump fleet to include DERS
software to reduce the risk of infusion medication and programming errors. Drug libraries
contain predefined parameters for some drugs including type, strength and dosing limits. By
upgrading the pumps, the system would establish drug concentrations, dose default rates, and
upper and lower dose limits (Ohashi et al., 2014).

The Fear of Infusion Errors

Since learning about intravenous medications, I have a growing fear of carrying out an
error with a miscalculation or input in infusion rate. I also fear I will forget to unclamp tubing in
order to infuse a prescribed drug on time. I intend to be diligent when programming my infusion
rates and I will have another nurse check them to be certain a mistake is not made. Though that
will reduce some errors with intravenous infusion, hospital procedure in keeping the pumps up-

MEDICATION ERRORS USING INFUSION PUMPS

to-date and in working order will similarly come into account. Hospitals need to update the
pumps frequently and look at data logs for quality improvement. Data collection and analysis
can prevent reoccurring errors and track the errors with medication errors through keystrokes
(Ohashi et al., 2014). As mentioned previously, focusing my attention on the task at hand and
also having a second nurse verify my infusion rate programming are ways in which I aim to
prevent this error from occurring. Other ways I intend to avoid this mistake is to familiarize
myself with the different intravenous medications and the pumps which infuse them.
Intravenous infusion of medications place patients within the hospital at risk. In the case
study discussed above, updating infusion pump software and having a second nurse verify the
settings would have prevented the complication with the patient. Hospital procedure in cleaning
and maintenance of infusion pumps should include an update of software monthly to improve
preventable complications from outdated pumps. Also, further analysis into each incident report
containing infusion rate errors should be required by the hospital for better quality improvement.
These considerations can help reduce infusion medication errors in healthcare settings.

MEDICATION ERRORS USING INFUSION PUMPS

References
Ibey, A. A., Ciarniello, C., & Gorelik, S. (2015, September 9). Inadvertent overinfusion of
NORepinephrine using infusion pump loading dose. Intensive and Critical Care Nursing.
http://dx.doi.org/10.1016/j.iccn.2014.12.001
Mason, J. J., Roberts-Turner, R., Amendola, V., Sill, A. M., & Hinds, P. S. (2014, March-April).
Patient Safety, Error Reduction, and Pediatric Nurses Perceptions of Smart Pump
Technology. Journal of Pediatric Nursing, 29, 143-151.
http://dx.doi.org/10.1016/j.pedn.2013.10.001
Ohashi, K., Dalleur, O., Dykes, P. C., & Bates, D. W. (2014, October 8). Benefits and Risks of
Using Smart Pumps to Reduce Medication Error Rates: A Systematic Review. Drug
Safety, 37, 1011-1020. http://dx.doi.org/10.1007/s40264-014-0232-1