Preventing Pump Programming Error with Concentration Changes

PLEASE NOTE:   Posts made to this forum should not be considered as the expressed opinions of, nor should be considered endorsed by, the Medication Safety Officer’s Society (MSOS) or the Institute for Safe Medication Practices (ISMP). 

Make sure your email is up-to-date
In order to continue to receive updates from MSOS, as well as forum posts and other valuable information as a member of MSOS, please be sure to update your email address with us, whenever it changes. If you need assistance doing so, please send an email to jrufo@ismp.org. 

2 posts / 0 new
Log in or register to post comments
Last post
Mon, 10/12/2020 - 19:56
#1
James Gibson
James Gibson's picture
Offline
Last seen: 1 day 20 hours ago
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

Tags: 

Top