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

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  • Eric S. Kirkendall

    (Wake Forest School of Medicine
    Department of Pediatrics, Wake Forest School of Medicine
    Cincinnati Children’s Hospital Medical Center
    University of Cincinnati College of Medicine)

  • Kristen Timmons

    (Cincinnati Children’s Hospital Medical Center)

  • Hannah Huth

    (Wake Forest School of Medicine
    Indiana University)

  • Kathleen Walsh

    (University of Cincinnati College of Medicine
    James M. Anderson Center of Health Systems Excellence)

  • Kristin Melton

    (University of Cincinnati College of Medicine
    Cincinnati Children’s Hospital Medical Center)

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.

Suggested Citation

  • Eric S. Kirkendall & Kristen Timmons & Hannah Huth & Kathleen Walsh & Kristin Melton, 2020. "Human-Based Errors Involving Smart Infusion Pumps: A Catalog of Error Types and Prevention Strategies," Drug Safety, Springer, vol. 43(11), pages 1073-1087, November.
    • Handle: RePEc:spr:drugsa:v:43:y:2020:i:11:d:10.1007_s40264-020-00986-5
    DOI: 10.1007/s40264-020-00986-5
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    Cited by:

    1. Adam Sutherland & Matthew D. Jones & Moninne Howlett & Sara Arenas-Lopez & Arif Patel & Bryony Dean Franklin, 2022. "Developing Strategic Recommendations for Implementing Smart Pumps in Advanced Healthcare Systems to Improve Intravenous Medication Safety," Drug Safety, Springer, vol. 45(8), pages 881-889, August.

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