Human-Based Errors Involving Smart Infusion Pumps: A Catalog of Error Types and Prevention Strategies

Eric S. Kirkendall (), Kristen Timmons, Hannah Huth, Kathleen Walsh and Kristin Melton
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Eric S. Kirkendall: Wake Forest School of Medicine
Kristen Timmons: Cincinnati Children’s Hospital Medical Center
Hannah Huth: Wake Forest School of Medicine
Kathleen Walsh: University of Cincinnati College of Medicine
Kristin Melton: University of Cincinnati College of Medicine

Drug Safety, 2020, vol. 43, issue 11, No 2, 1073-1087

Abstract: Abstract Over 4000 preventable injuries due to medication errors occur each year in any given hospital. Smart pumps have been widely introduced as one means to prevent these errors. Although smart pumps have been implemented to prevent errors, they fail to prevent specific types of errors in the medication administration process and may introduce new errors themselves. As a result, unique prevention strategies have been implemented by providers. No catalog of smart pump error types and prevention strategies currently exists. The aim of this study is to review and catalog the types of human-based errors related to smart pump use identified in the literature and to summarize the associated error-prevention strategies. We searched MEDLINE, PubMed, PubMed Central, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for literature pertaining to human-based errors associated with smart pumps. Studies related to smart pump implementation, other types of pumps, and mechanical failures were excluded. Final selections were mapped for error types and associated prevention strategies. A total of 1177 articles were initially identified, and 105 articles were included in the final review. Extraction of error types and prevention strategies resulted in the identification of 18 error types and ten prevention strategies. Through a comprehensive literature review, we compiled a catalog of smart pump-related errors and associated prevention strategies. Strategies were mapped to error types to provide an initial framework for others to use as a resource in their error reviews and improvement work. Future research should assess the application of the resources provided by this review.

Date: 2020
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DOI: 10.1007/s40264-020-00986-5

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