Preventing Pump Programming Error with Concentration Changes

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Mon, 10/12/2020 - 19:56
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James Gibson
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Joined: 09/27/2019 - 11:57
Preventing Pump Programming Error with Concentration Changes

We have occasional issues where a higher concentration of a continuous infusion (e.g. dobutamine 4mg/mL instead of our standard 1 mg/mL) is intentionally dispensed but the nurse who hangs the bag and programs the pump does not notice that the concentration is different than the prior bag. This results in over/under dosing. These errors have occurred both when pharmacists change the concentration in an attempt to minimize bag changes for nurses, and when nurses have specifically asked for the higher concentration but either forget to update the pump or another nurse is the one who actually hangs the new bag and isn't aware of the change.

I would be interested in any workflow, Smart Pump, or EHR/alert changes you may have implemented and found effective at preventing such issues.

Thank you,
James Gibson
UW Medicine

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