Although administering intravenous (IV) medication via smart infusion pumps has led to improvements in patient safety, common errors persist with the use of these devices, according to a presentation at the American Society of Health System Pharmacists Midyear Clinical Meeting and Exhibition.

During a symposium on smart pump technology, Michelle Mandrack, the director of consulting services for the Institute of Medication Practices (ISMP), stated that while IV administration is clinically advantageous, there have been errors reported with IV infusion pumps.

Smart infusion pumps, she explained, were developed to prevent potentially fatal over-infusions or under-infusions, and have provided health care professionals with an opportunity to establish standard practices on drug concentrations and dosing units. The pumps have been increasingly adopted by health care facilities since their introduction, with 52% of hospitals reporting their use in 2008 and 84% doing so in 2017.

Despite its advantages, there remains limitations to smart pump technology, Mandrack noted. Specifically, smart infusion pumps:
  • Are not assigned to individual patients
  • Are not associated with intended therapy
  • Cannot prevent wrong drug selection
  • Do not intercept drug mix-ups
  • Often operate independently of other technology
As a result, human error—including bolus dosing errors, secondary infusion errors, dosing nomenclature errors, dose-rate confusion errors, and manual programming errors—can cause smart pumps to dispense the correct medication or dosage.

Mandrack added, however, that these safety gaps are not exclusive to smart pump technology, but rather highlight larger problems with IV infusion.

“Smart pumps have shined a bright light on the vulnerabilities of IV medications,” she said.

 Emphasizing the importance of taking an interdisciplinary approach in addressing these challenges, Mandrack indicated that building and maintaining drug libraries, integrating systems, and encouraging staff feedback would help to minimize errors associated with the use of smart infusion pumps.

“Establishing a culture of safety is fundamental to maximizing the benefits of smart pump technology,” she concluded.


Mandrack M. Smart Pump Technology: Recognizing the Gains and Addressing the Gaps. Presented at: American Society of Health System Pharmacists Midyear Clinical Meeting and Exhibition. December 4, 2017. Orlando, Florida.