Implementing and evaluating the patient safety benefits of dose error reduction software in electronic infusion devices in an NHS Hospital Trust

Abstract

A review of all dose error reduction software (DERS) alerts displayed in electronic infusion devices (‘smart pumps’) was undertaken in an NHS Hospital Trust over 12 months. There were 265 880 infusion starts recorded. The majority of infusions (173 891 (65.4%)) were found to have been started using the DERS settings. Some 3700 (1.4%) infusion starts caused a DERS alert to be displayed to the user. Of these, 831 (0.3%) were above the hard dose rate limit and 1331 (0.5%) above and 1538 (0.6%) below the soft dose rate limits. Of these, 317 (8.6%) resulted in the ‘error’ being corrected by reprogramming the infusion rate within set limits, 478 (12.9%) were cancelled and 2452 (66.3%) were over-ridden with the rate of infusion unchanged. For 453 (12.2%) the actions were not recorded in a way that could be included in reports for analysis. Implementation of this technology has enabled infusion rate errors involving critical infusions containing high alert medicines to be avoided. These types of infusion errors could also be avoided in other NHS Trusts if DERS were used.