Do Smart Pumps Actually Reduce Medication Errors

There is growing evidence that medication errors are prevalent in healthcare, with one estimate that there is at least one medication error per hospital patient per day.1 This is partly due to the complexity of the medication process. Unfortunately, its intricacies are mirrored in the daunting list of potential interventions (e.g., improve medication labeling, implement double check procedures, create training programs and/or implement new technologies). As a result, healthcare providers are currently grappling with how best to proceed. A framework for intervention design was presented in a “Medication Safety Alert!” bulletin published by the Institute for Safe Medication Practices (ISMP) to help prioritize effective changes for safe medication use.2 This is commonly referred to as the hierarchy of effectiveness, and it categorizes interventions into six levels, with the most effective at preventing errors at the top and the least effective at the bottom. Figure 1 provides further information regarding each level of the hierarchy, but the top three levels can be described as design-oriented strategies and the bottom three levels as person-oriented strategies. While effective error prevention often requires the use of strategies at all levels of this hierarchy, generally strategies that change the system (i.e., design-oriented) provide more effective and longer lasting safety benefits than those that rely on the vigilance of people (i.e., personoriented). That is, the hierarchy suggests that interventions aimed at correcting user behavior (e.g., relying on training personnel) are often not effective because they do not address the underlying systemic issues that lead to errors. As shown in Figure 1, tools that remove the potential for an error to occur are ideal. Failing this, tools that change the system to minimize, or ideally remove, the reliance on human weaknesses, such as memory and communication of complex information (e.g., illegible hand writing, communicating verbatim), are preferred. Tools that rely too heavily on users’ attentiveness, complicated processes and systems, or people detecting their own or others’ errors are usually less effective. Do Smart Pumps Actually Reduce Medication Errors?