'Smart' intravenous pumps: how smart are they?

To cite: Franklin BD. BMJ Qual Saf Published Online First: [please include Day Month Year] doi:10.1136/ bmjqs-2016-005302 Smart pumps, incorporating dose error reduction software, are widely promoted as a patient safety intervention. 2 This software checks programmed intravenous infusion rates against preset limits for each drug in the pump’s ‘drug library’ with the aim of reducing the risk of infusion rates that are too high or too low. Smart pumps were reported to be in use in 68% of US hospitals in 2011, although this figure does not tell about how they are used nor in which clinical areas. A UK study indicated less widespread use and that although smart pumps may be in use within an organisation, they may only be used in some clinical areas or for certain kinds of infusion. Although widely advocated, as with many other patient safety interventions, the evidence for smart pumps’ benefit is not clear-cut. No conclusive evidence shows that smart pumps do indeed prevent medication errors and adverse drug events, and we know little about the kinds of errors that still occur with their use. 9 In this issue, Schnock et al aim to shed light on some of these issues by documenting the prevalence and types of errors associated with intravenous infusions in 10 US hospitals using smart pumps. Pairs of observers visited participating clinical areas and identified discrepancies between each infusion and its corresponding medication order plus relevant organisational policies. This method can reveal only errors visually apparent from an infusion in progress. Any errors in the preparation of the infusion, such as the wrong concentration being prepared, will not be identified unless the corresponding label is also incorrect. This approach also focuses on errors in medication administration and does not include prescribing errors involving incorrect infusion rates, which smart pumps may also have a role in preventing. Even so, the paper suggests a very high error rate, with 60% of 1164 observed infusions reported as having one or more errors. At face value, this figure seems very high, but it includes procedural violations as well as what would usually be considered to be medication administration errors and, as the authors point out, very few (5 of the 1691 errors identified in 1164 infusions) were judged to be potentially harmful. The five potentially significant medication administration errors comprised four ‘errors that would have required increased monitoring to preclude harm’ (category D) and one ‘error likely to cause temporary harm’ (category E). The four category D errors consisted of two wrong rate errors, one omission error and one expired drug error; the category E error was an omission error. The error rate based on these five more serious errors is just 0.4% of infusions—more than a hundred times lower than the headline figure of 60%—perhaps suggesting that intravenous infusions are relatively safe. This 100-fold discrepancy highlights two issues. The first is the extent to which procedural violations are important. On the one hand, procedural violations may be a useful indicator of the underlying culture and may affect whether or not patients feel that their care is safe. One study showed an association between a particular procedural violation (not checking patient identification) and medication administration errors, with the authors suggesting that not checking patient identity may indicate a general failure to follow administration protocols. On the other hand, including minor procedural failures that do not result in medication administration errors may detract from the more important issues and risk creating the perception of the research being less relevant to practice. For example, Schnock et al included procedural issues such as discontinued infusions being disconnected from the patient but still connected to the pump, which are unlikely to be considered EDITORIAL