The Potential Role of Smart Infusion Devices in Preventing or Contributing to Medication Administration Errors: A Descriptive Study of 2 Data Sets

J Patient Saf. 2021 Dec 1;17(8):e1894-e1900. doi: 10.1097/PTS.0000000000000751.


Objectives: Errors in medication administration are common, with many interventions suggested to reduce them. For intravenous infusion-related errors, "smart infusion devices" incorporating dose error reduction software are widely advocated. Our aim was to explore the role of smart infusion devices in preventing or contributing to medication administration errors using retrospective review of 2 complementary data sets that collectively included a wide range of errors with different levels of actual or potential harm.

Methods: We reviewed 216 medication administration errors identified from an observational study in clinical practice and 123 medication incidents involving infusion devices reported to a national reporting system. The impact of smart infusion devices in preventing or contributing to these errors was assessed by the research team and an expert panel.

Results: The data suggest that use of any infusion device rather than gravitational administration may have prevented 13% of observed errors and 8% of reported incidents; additional reductions may be possible with standalone smart infusion devices, and further potential reductions with smart infusion devices integrated with electronic prescribing and barcode administration systems. An estimated 52% to 73% of errors that occurred with traditional infusion pumps could be prevented with such integrated smart infusion devices. In the few cases where smart infusion devices were used, these contributed to errors in 2 of 58 observed errors and 7 of 8 reported incidents.

Conclusions: Smart infusion devices not only prevent some medication administration errors but can also contribute to them. Further evaluation of such systems is required to make recommendations for policy and practice.

Publication types

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

MeSH terms

  • Electronic Data Processing
  • Electronic Prescribing*
  • Humans
  • Infusion Pumps
  • Infusions, Intravenous
  • Medication Errors* / prevention & control