Use of an infusion pump may be associated with a number of adverse events. These can be prevented by addressing the sources of potential error.
Source of problems:
(1) misusing the equipment
(2) using a pump with no or limited free-flow protection
(3) miscalculating a drug dose
(4) incorrect programming of the pump
(5) hanging the wrong medication
(6) device (hardware or software) failure
(7) failing to adequately educate staff on the use of the equipment
(8) excessive workload or chaotic work environments
(9) use of different kinds of equipment with different operating features
Free-flow refers to free flow of the infusate into the patient. This may occur:
(1) if the pump is designed to open maximally when a fault occurs (rather than close completely)
(2) when tubing is disconnected from the pump during patient transfers or imaging studies
Steps to prevent adverse events:
(1) Educate healthcare providers in the proper use and operation of infusion pumps.
(2) Take steps to minimize unauthorized changes to the pump's program.
(3) Providing anti-free-flow protection by removing substandard infusion pumps and using systems designed to minimize free-flow.
(4) Double checking of dosage calculations especially those involving high risk medications.
(5) Standardize dosing and concentrations to reduce chances for dosing error.
(6) Standardize equipment to reduce chances of usage errors.
