AAMI is reporting the results of a new study published in BMJ Quality & Safety which shows that more than half of infusions of intravenous (IV) medications contained some type of error. Most were unlikely to cause patient harm, but the majority were linked to problems with clinical practice rather than technology. The findings point to new complexities about preventing infusion pump errors, including the need for consistent clinical practices and improved interoperability.

Led by David Bates, MD, senior vice president and chief innovation officer at Brigham and Women’s Hospital in Boston, the research team evaluated 1,164 medication administrations conducted at 10 different hospitals, all of which used smart pumps. The pumps themselves represented a variety of manufacturers. The study found that 60% of infusions contained at least one error. Of the detected errors, approximately 65% were due to violations of IV labeling and tubing change policies, which AAMI says vary between hospitals.

“Since these errors are not directly related to the use of smart pumps, these finding suggest that smart pump technology alone cannot fully prevent errors associated with intravenous infusions,” the report states.

However, in the case of potentially dangerous errors—such as infusing medication at the wrong rate, administering the incorrect medication, or failing to infuse a necessary medication—the researchers noted that “closed-loop interoperability” between a smart pump and the facility’s electronic health record (EHR) could have helped prevent them. Under a closed-loop system, smart pumps automatically import a medication order from a patient’s EHR. A nurse must accept and verify the data, including the medication name, infusion rate, volume, and concentration, before the order goes into effect.

The study was funded by the AAMI Foundation with a grant provided by BD. For more information, visit the AAMI website.