Programmable Infusion Pumps in ICUs: An Analysis of Corresponding Adverse Drug Events

J Gen Intern Med. 2008 Jan;23 Suppl 1(Suppl 1):41-5. doi: 10.1007/s11606-007-0414-y.


Background: Patients in intensive care units (ICUs) frequently experience adverse drug events involving intravenous medications (IV-ADEs), which are often preventable.

Objectives: To determine how frequently preventable IV-ADEs in ICUs match the safety features of a programmable infusion pump with safety software ("smart pump") and to suggest potential improvements in smart-pump design.

Design: Using retrospective medical-record review, we examined preventable IV-ADEs in ICUs before and after 2 hospitals replaced conventional pumps with smart pumps. The smart pumps alerted users when programmed to deliver duplicate infusions or continuous-infusion doses outside hospital-defined ranges.

Participants: 4,604 critically ill adults at 1 academic and 1 nonacademic hospital.

Measurements: Preventable IV-ADEs matching smart-pump features and errors involved in preventable IV-ADEs.

Results: Of 100 preventable IV-ADEs identified, 4 involved errors matching smart-pump features. Two occurred before and 2 after smart-pump implementation. Overall, 29% of preventable IV-ADEs involved overdoses; 37%, failures to monitor for potential problems; and 45%, failures to intervene when problems appeared. Error descriptions suggested that expanding smart pumps' capabilities might enable them to prevent more IV-ADEs.

Conclusion: The smart pumps we evaluated are unlikely to reduce preventable IV-ADEs in ICUs because they address only 4% of them. Expanding smart-pump capabilities might prevent more IV-ADEs.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Adverse Drug Reaction Reporting Systems / instrumentation*
  • Aged
  • Critical Illness
  • Drug Therapy, Computer-Assisted*
  • Equipment Design
  • Equipment Safety
  • Female
  • Humans
  • Infusion Pumps / standards*
  • Infusion Pumps / trends
  • Infusion Pumps, Implantable / standards
  • Infusion Pumps, Implantable / trends
  • Intensive Care Units
  • Male
  • Medical Records
  • Medication Errors / prevention & control*
  • Middle Aged
  • Probability
  • Retrospective Studies
  • Risk Management
  • Sensitivity and Specificity