Risk of Medication Errors With Infusion Pumps

A Study of 1,004 Events From 132 Hospitals Across Pennsylvania

  • Matthew A. Taylor Patient Safety Authority
  • Rebecca Jones Patient Safety Authority
Keywords: infusion pump, IV pump, smart pump, medication error, risk factors, adverse events, patient safety, Pennsylvania, high-alert medication, medical device

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.

Author Biographies

Matthew A. Taylor , Patient Safety Authority

Matthew A. Taylor (MattTaylor@pa.gov) is a patient safety analyst for the Patient Safety Authority, where he conducts research; uses data to identify patient safety concerns and trends; and develops solutions for safety issues, as well as tools and materials to help facilities and clinicians improve patient safety. Prior to joining the PSA, Taylor was a scientific writer and research specialist at the University of Pittsburgh School of Pharmacy, and he has served fellowships at the Centers for Disease Control and Prevention and the VA Pittsburgh Healthcare System. His expertise in data analysis and research covers a range of topics, including patient safety, public health, employee training, process efficiency, human factors, workplace culture/climate, behavior change interventions, and organizational management.

Rebecca Jones, Patient Safety Authority

Rebecca Jones is director of Data Science and Research at the Patient Safety Authority, where she also founded and serves as director of the Center of Excellence for Improving Diagnosis. Her previous roles at the PSA include director of Innovation and Strategic Partnerships, and regional patient safety liaison. Before joining the PSA, Jones served in various roles leading patient safety efforts and proactively managing risk in healthcare organizations. She currently is chair of the Practice Committee of the Society to Improve Diagnosis in Medicine and serves on the Advisory Committee of the Coalition to Improve Diagnosis.

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Published
2019-12-17
How to Cite
Taylor , M. A., & Jones, R. (2019). Risk of Medication Errors With Infusion Pumps: A Study of 1,004 Events From 132 Hospitals Across Pennsylvania. Patient Safety , 1(2), 10. https://doi.org/10.33940/biomed/2019.12.7
Section
Original Research and Articles
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