To identify the key issues around use of computerized patient infusion devices (called
To develop strategies that will improve the prevention of intravenous errors that will be
The investigators will conduct a national study using the general methodology developed by
Husch et al. to allow a rapid assessment of the frequency and types of medication errors at
The key questions the investigators will address are:
1. What are the frequency and types of intravenous medication errors?
2. How much variability is there by frequency and type among settings?
3. After review of the initial data, what strategies appear to have the greatest potential
for reducing intravenous medication error frequency?
4. How effective is an intervention including a bundle of these strategies at multiple
Overall Study Design: This is a multi-hospital study to investigate medication errors using
smart pumps. The proposed study will be conducted over three phases for a total of 36 months
phases. In Year 1, an observational study will be conducted by investigators at ten multiple
hospital sites. The investigators will prospectively compare the medication, dose, and
infusion rate on the IV pump with the prescribed medication, doses, and rate in the medical
record. Preventability with smart pump technology will be retrospectively determined based
on a rigorous definition of currently available technology. The investigators will also make
comparisons across sites by overall rate and degree of variability among sites.
Then, in Year 2, these results will be evaluated, and a consensus process including a
face-to-face meeting will take place to evaluate the types of events and to develop an
intervention which will be implemented at multiple sites. After a run-in period, the
intervention will be tested in Year 3 at the sites, and the data will be analyzed, and the
investigators will produce a report and a set of recommendations.
- Patients if they receive any IV fluid or medication on the day of observation in the
- patients who are under 21 years old.