O0001 Oct.4: 3:05pm - Human-based Errors Involving Smart Infusion Pumps; A Narrative Summary of Error Types and Prevention Strategies

Over 4000 preventable injuries due to medication errors occur each year in any given hospital. Smart pumps have been widely introduced as one means to prevent these errors. Although smart pumps have been implemented to prevent errors, they fail to prevent specific types of errors in the medication administration process and may introduce new errors themselves. As a result, unique prevention strategies have been implemented by providers. No catalog of smart pump error types and prevention strategies currently exist. To review and catalog the types of human-based errors related to smart pump use identified in the literature and to summarize the associated error prevention strategies. Literature pertaining to human-based errors associated with smart pumps was searched in MEDLINE, PubMed, PubMed Central, and CINAHL. Studies related to smart pump implementation, other types of pumps, and mechanical failures were excluded. Final selections were mapped for error types and associated prevention strategies. A total of 1,117 articles were initially identified, and 105 articles were included in the final review. Extraction of error types and prevention strategies resulted in the identification of 26 error types and 10 prevention strategies. Through a robust literature review, we compiled a catalog of smart pump-related errors and associated prevention strategies. Strategies were mapped to error types to provide a framework for the study and prevention of future errors. Future research should assess the effectiveness of strategies developed to prevent medication errors, as well as the application of the resources provided by this review.