We have had a chronic, low level issue of pump programming errors for norepinephrine infusions in which the RN misses a zero in the dose field when titrating norepinephrine resulting in 10-fold overdoses (e.g. 0.8 mcg/kg/min programmed instead of the intended 0.08 mcg/kg/min). We occasionally have reports of under-doses as well when an extra zero is added to the dose by mistake.

We have found this difficult to prevent with Guardrails given the wide usual dosing range of norepinephrine (0.01 to 1 mcg/kg/min). Ideally the smart pump could alert if the dose was changed by a large percentage, but this is not possible with the Alaris pumps we utilize.

Have any sites found a creative way to help avoid these 10-fold dosing errors with norepinephrine or similar medications?

Some info about our set-up:
- We only allow weight-based dosing (mcg/kg/min) of norepinephrine. Default allowed titration range of 0 to 1 mcg/kg/min
- We use Alaris pumps
- Soft min dose of 0.01 mcg/kg/min; soft max dose of 0.9 mcg/kg/min. No hard min/max set
- We do NOT have interoperability at this time
- We utilize Epic for our EHR.

Thank you,
James Gibson