Tubing Misload Allows Free Flow Event with Smart Intravenous Infusion Pump
Schroeder, Mark E., MD; Wolman, Richard L., MD; Wetterneck, Tosha B., MD; & Carayon, Pascale, PhD. (2006). Anesthesiology: 105:2, 434-435.
http://cqpi.engr.wisc.edu/system/files/Schroederetal2006_Tubing.pdf
The use of "smart" intravenous infusion pumps incorporating microcomputer technology holds the promise of safer medication administration and is endorsed by ECRI (formerly the Emergency Care Research Institute).1 A sophisticated feature of smart pumps is the medication library for particular patient types or care venues. Drugs in the library are given absolute (hard) or advisory (soft) preprogrammed dosing limits. The user selects the appropriate library, drug, and concentration, thereby invoking the limits for that medication. If a limit is breached, an alarm is both seen and heard. An "anesthesia mode" within each library allows prolonged pause, alarm management, and dose limits specific for the operating room.
After an intensive multidisciplinary study that included review of safety data, a return-on-investment analysis, a failure mode and effects analysis, and a usability trial, the University of Wisconsin Hospital and Clinics selected and implemented the Alaris Medley Medication Safety System intravenous pump (ALARIS Medical Systems, Inc., San Diego, CA) in October 2003. Before use in the operating room, training to highlight pump safety features, setup, programming, and capabilities was mandated for all anesthesia providers.