Risk of Medication Errors With Infusion Pumps: A Study of 1,004 Events From 132 Hospitals Across Pennsylvania

Abstract

The risk of medication errors with infusion pumps is well established, yet a better under-standing is needed of the scenarios and factors associated with the errors. Our study ex-plored the frequency of medication errors with infusion pumps, based on events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) during calendar year 2018. Our study identified a total of 1,004 events involving a medication error and use of an infusion pump, which occurred at 132 different hospitals in Pennsylvania. Fortunately, a majority of medication errors did not cause patient harm or death; however, we did find that 22% of events involved a high-alert medication. Our study shows that the frequency of events varies widely across the stages of medication process and types of medication error. In a subset of our data, we manually reviewed a free-text narrative field in each event report to better un-derstand the nature of errors. For example, we found that a majority of wrong rate errors led to medication being infused at a faster rate than intended, and user programming was the most common contributing factor. Overall, results from our study can help providers identify areas to target for risk mitigation related to medication errors and the use of infusion pumps.

Keywords

• infusion pump, IV pump, smart pump, medication error, risk factors, adverse events, patient safety, Pennsylvania, high-alert medication, medical device