ABSTRACT. Objective. To determine if combining standard drug concentrations with "smart-pump" technology reduces reported medication-infusion errors. Design. Preintervention and postintervention comparison of reported medication errors related to infusion therapies during the calendar years 2002 and 2003.Setting. A 242-bed university-affiliated tertiary pediatric hospital.Intervention. Change in continuous-medication-infusion process, comprising the adoption of (1) standard drug concentrations, (2) "smart" syringe pumps, and (3) human-engineered medication labels. Main Outcome Measures. Comparison of reported continuous-medication-infusion errors before and after the intervention.Results. The number of reported errors dropped by 73% for an absolute risk reduction of 3.1 to 0.8 per 1000 doses. Preparation errors that occurred in the pharmacy decreased from 0.66 to 0.16 per 1000 doses; the number of 10-fold errors in dosage decreased from 0.41 to 0.08 per 1000 doses.Conclusions. The use of standard drug concentrations, smart syringe pumps, and user-friendly labels reduces reported errors associated with continuous medication infusions. Standard drug concentrations can be chosen to allow most neonates to receive needed medications without concerns related to excess fluid administration. M edication errors are a major source of potential and actual harm in pediatric patients. [1][2][3] Pediatric patients are at greater risk for medication error than adult patients because of the need for weight-based dosing and individualized dose calculation for most medications. Effective communication about symptoms and elicitation of pertinent clinical findings is often difficult in children. 2,4 Medical complexity and the need for multiple medications places hospitalized children at an even greater risk; nowhere is this more evident than in intensive care units. [2][3][4][5] Continuous medication infusions are a category of medications delivered to hospitalized patients that often include "high-alert" medications. As defined by the Institute of Safe Medication Practice, highalert medications are drugs that bear a heightened risk of causing significant patient harm when used in error and may lead to devastating complications for patients. 6 The process of ordering, preparing, and administering continuous medication infusions offers several opportunities for error. 4,[7][8][9] Providing the correct weight-adjusted dose (at an acceptable rate, concentration, and volume) usually requires a multivariable calculation; moreover, a new calculation must be performed whenever the dose is changed. The need for individualized concentrations makes drip preparation a high-frequency and time-consuming task for the pharmacy. The appropriate information must be entered correctly into the pump initially and when changes are made.Several common practices influence the likelihood of continuous-medication-infusion errors. The "rule of 6" is a calculation aid that was developed originally to facilitate rapid dose calculation and drip preparation in ...

Preventable adverse events occurred fairly frequently in the pediatric intensive care unit, but serious harm was rare. Conditions that increased the likelihood of a preventable adverse event were a) need for sedation or pain control; b) relative immobility; and c) need for vascular devices, feeding tubes, or ventilators. Adverse event prevention strategies that focus on improving patient monitoring under increased-risk conditions and improving early detection and treatment of potential harm will likely be more effective than strategies aimed at general error prevention.

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