This study adds to the literature by explicitly comparing and quantifying the effects of pump types on the nurses' ability to safely administer IV medication and by identifying errors that are not addressed by current pumps. Certain errors that were potentially preventable by smart pumps or barcode pumps (eg, soft limit overdose errors) were due to deviations from policies.
Our findings are consistent with other studies,8 10 11
which showed that nurses often override soft limit alerts when clinically inappropriate. Furthermore, our findings suggest that when faced with hard limit warnings, nurses respond in a safe manner. However, many hospitals do not implement the hard limit feature. Other errors (eg, secondary infusion errors), were not preventable by smart or barcode technologies.
Our results are also consistent with other findings,21
indicating that errors related to setup and administration of secondary infusions have lead to adverse events. Furthermore, researchers18 22 23
have reported that confusion between dosing units and/or concentrations when using smart pumps lead to overdoses. Our findings concur and provide further evidence that variation in IV medication practices is associated with increased risks.
Finally, our results show that some errors (eg, undetected wrong drug errors) were due to a lack of integration between the pump and other components (eg, CPOE) of the medication delivery system. Thus, effective use of pump technology is dependent not only on the design of the pump itself but also on the way it is implemented. Institutions must promote a culture of safety that encourages nurses to think critically, evaluate pump warnings and limit overrides to circumstances that have been carefully assessed.
It has been estimated that approximately 44.0% of US hospitals use smart pumps.24
To optimise integration of smart pumps, healthcare institutions must dedicate a significant operational budget to cover costs including maintenance and licensing, drug library updating, continuous quality improvement analysis/reporting and costs related to training and maintaining nurse proficiency. Currently, hospitals may be investing three to four times more money into smart pumps compared to traditional pumps without realising noteworthy safety benefits.
While pumps with barcoding hold a lot of promise, smart pump and IT vendors have not yet fully established an integrated approach that ensures connectivity between medication management technologies. Our findings show that until hospitals can achieve full connectivity between technologies, barcode pumps will help prevent certain errors that earlier pump versions could not address (eg, wrong patient errors), but will continue to permit others (eg, wrong drug).
There are limitations to our study. The small sample size and the simulation of a real inpatient unit limit the generalisability of the results. However, significant differences were detected nonetheless. The large number of planted errors might have influenced participants to behave differently (eg, be more alert to errors) than they would under clinical circumstances where these errors occur less frequently. Participants had no previous experience with smart pumps. Therefore, results are representative of nurses who receive vendor training but have little experience using the technology. Although our results can be generalised to a novice smart pump user population, they are consistent with findings from studies where nurses had experience with smart pumps. For example, our results are coincident with researchers who found that nurses often override smart pump safety limits.8 10 11
It is possible that nurses in this study overrode limits to please the researcher and carry out instructions as indicated. This is unlikely, however, given that participants were explicitly asked to underscore problematic drug orders. Researchers have found that safety overrides are frequently due to alert fatigue, a mental state resulting from many alerts consuming time and mental energy.25–29
Other researchers attribute overrides to alerts being lengthy, difficult to interpret and lacking clarity as to clinical consequences.29 30
A deeper understanding of how to design effective alerts could be developed by assessing the following: (a) how cognitive processes contribute to clinicians' response to alerts; (b) clinicians' reasons for overriding alerts (eg, ignore, misinterpret, incorrect selection); (c) how to incorporate effective handling of safety alerts without interrupting workflow and (d) how to increase clinician trust and responsiveness to smart pump alerts. Future work should also focus on achieving safer systems by integrating components at various stages (eg, ordering, prescribing, administering) of the medication delivery process.