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Problem

1. When manually programming an infusion pump, a nurse may accidentally enter the volumetric flow rate into the pump's dose rate field (or vice versa), potentially leading to a dangerous medication administration error.

2. Other wrong-field programming errors—such as entering the dose rate into the volume to be infused (VTBI) field or the flow rate into the patient weight field, to name just a few—are possible and can have similar consequences.

3. Factors that can contribute to wrong-field programming errors include:

a) The manner in which the facility's infusion pumps are programmed (i.e., autoprogramming versus manual programming)

b) The configuration of an infusion pump's programming screen

c) The sequence in which infusion programming parameters are listed on the medication administration record

d) The absence of procedures to verify the accuracy of pump programming (e.g., an independent double-check on select medications)

4. An infusion pump's dose error reduction system will catch some, but not all, of these programming errors. Appropriately set soft limits still allow a wide range of acceptable programming, and it is possible to administer a dangerously incorrect amount of drug while being within the acceptable range.

5. Such a programming error can lead to patient harm or even death. Adverse outcomes are more likely with high-alert medications such as heparin or dopamine.

ECRI Institute Recommendations

1. If possible, implement infusion pump autoprogramming, which effectively eliminates programming errors related to manual entry of infusion parameters. Note that autoprogramming still requires the nurse at the bedside to review and verify the pump's programming before starting an infusion.

2. If autoprogramming is not possible at this time:

a) Train nurses on the correct method to program infusion parameters into pumps:

(1) Most infusion pumps that allow dose rate programming—these are commonly referred to as "smart" pumps—list dose rate first in the programming screen. For these pumps, nurses should enter the dose rate from the medication administration record. The pump will calculate the volumetric flow rate from the medication's concentration.

(2) However, one widely adopted smart pump lists volumetric flow rate first in the programming screen. Facilities with such pumps will need to decide if they prefer nurses to enter volumetric flow rate (since that is listed first) and let the pump calculate dose rate, or enter dose rate (since that is more clinically meaningful) and let the pump calculate volumetric flow rate.

b) If possible, configure your electronic medication administration record to list the infusion programming parameters in the order you want your nurses to enter them into the pump.

c) Train nurses to check both the dose rate and volumetric flow rate as programmed into the pump against the record before starting an infusion. If this type of programming error has occurred, one of these numbers will not match. For example, if the nurse has mistakenly entered the volumetric flow rate from the record into the dose rate field on the pump, those numbers on the record and the pump will match, but the other two—the dose rate on the record and the volumetric flow rate calculated by the pump—will not.

d) Consider implementing an independent double check on select high-alert medications. A properly conducted independent double check during pump programming should catch this type of programming error. Such a check entails a second nurse separately reviewing the programming parameters on the pump's programming screen and comparing them to the record. Because independent double-checks are time-intensive, they are not appropriate to use every time a pump is programmed. But they can be effective if used judiciously. (For additional discussion, see ISMP's article on the subject.)

Background

1. Infusion pumps are used to accurately deliver medications and other solutions through intravenous or epidural routes at a specified rate. If the rate that is programmed into the pump is incorrect, the patient will receive either too much or too little solution. Either situation can have grave consequences for the patient, depending on the solution being delivered.

2. "Smart" infusion pumps, which account for the vast majority of pumps in use today, incorporate a dose error reduction system to help prevent such programming errors. However, even these pumps can be misprogrammed in a way that leads to patient harm.

3. Manually programming an infusion into a smart pump requires the nurse to do the following:

a) Select the appropriate clinical category (e.g., ICU).

b) Select the drug and concentration. For most drug libraries, this is a two-step process: selecting the drug, and then picking from the available concentrations for that drug. Some drug libraries present all available drug concentrations in a single list for each clinical category.

c) Enter the patient's weight (only for drugs that are dosed based on weight).

d) Enter either the dose rate or the volumetric flow rate. When one of these is entered, the pump calculates the other from the concentration and displays that value on the programming screen in the appropriate location.

e) Enter either the VTBI or the duration of the infusion. When one of these is entered, the pump calculates the other from the volumetric flow rate and displays both values on the programming screen in the appropriate locations.

4. As noted above, it is possible to administer a dangerously incorrect amount of a drug even with a pump that incorporates dosing safeguards.

5. Clinicians have informed ECRI Institute that medication errors related to wrong-field entry during manual infusion pump programming occur relatively frequently. However, such errors are not typically reported and do not show up in the pump analytics reports that are generated periodically.

6. Following are two examples of wrong-field programming errors that were reported to ECRI Institute PSO, a federally designated patient safety organization (PSO). (Under federal law, healthcare organizations can voluntarily share their safety surveillance data with PSOs in a protected legal environment. PSOs analyze the aggregated data and share the findings and lessons learned.)

a) A patient was hypotensive and required 0.2 mcg/kg/min of norepinephrine after being administered propofol at what a resident thought was a dose rate of 30 mcg/kg/min. However, the pump was actually programmed to deliver at a flow rate of 30 mL/hr, which corresponds to a dose rate of 87 mcg/kg/min. The fact that propofol was being infused at nearly three times the intended dose rate contributed to the hypotension.

b) A patient was transferred to the ICU from the emergency department (ED) on a ventilator. The ED nurse said the patient had propofol infusing "at 30." The intended rate was probably a dose rate of 30 mcg/kg/min, but when the pump was checked, propofol was infusing at a flow rate of 30 mL/hr. That flow rate equated to a dose rate of 68 mcg/kg/min, well above the highest dose the nurse is allowed to titrate propofol. Because the dose of propofol was so high, the patient's blood pressure dropped, and the patient was obtunded and difficult to arouse.