Although smart infusion pumps are intended to prevent medication errors by alerting users about doses that exceed set thresholds, a large number of clinically insignificant alarms and alerts create the potential for alert and alarm fatigue. We searched the PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases for peer-reviewed literature (January 1, 2004-August 31, 2017) on managing smart pump alerts, alarms, and related fatigue. Twenty-nine articles that met the inclusion criteria were reviewed and organized into themes. Smart pumps give users two types of signals: alarms that indicate mechanical issues such as occlusion, air in the line, or low battery; and clinical alerts that indicate that a programmed dose exceeds a predefined safety limit. Mechanical alarms occur with greater frequency than clinical alerts, but alarms and alerts vary widely by pump model, patient population, time of day, month, and type of drug. Several causes of clinically insignificant alerts and alarms may be actionable, and strategies proposed in the literature include development of a multidisciplinary team to oversee the quality improvement effort with involvement of end users, standardization of medication administration practices, widening of drug limit library thresholds when clinically appropriate, maintaining up-to-date drug limit libraries, and interoperability. Whereas many strategies have been proposed, and case studies have been reported, none have been rigorously evaluated. In addition, more research is needed related to managing occlusion and air-in-line alarms, especially for complicated infusions. Future work should focus on the evaluation of specific and replicable alert and alarm reduction strategies with a greater emphasis on quantitative metrics.

Tyco Healthcare, Portsmouth) were applied before sedation (0.5 mg midazolam + £ 0.05 lg.kg )1 .min )1 remifentanil) and supplemental oxygenation. Deep and superficial cervical plexus blocks were performed using 20 ml bupivacaine 0.5%, and 28% oxygen given by Venturi facepiece. Peri-operative blood pressure was maintained at £ 10% above the patient's normal limits during carotid cross-clamping. Five minutes after clamping, 100% oxygen was given by close-fitting anaesthetic facepiece. After another 5 min, the oxygen mask was removed and the patient breathed room air. Effects on rSO 2 readings and arterial blood gases were observed after each intervention. Data analysis was by paired t test. ResultsAll 15 patients (M:F 11:4; mean (SD) age 69 (10) years) completed the study. Ipsilateral rSO 2 values fell by 7.4 (5%) after carotid cross-clamping (contralateral values unchanged; Fig. 1 . The American College of Cardiology/American Heart Association (AHA) guidelines recommend preoperative echocardiography in patients with decompensated heart failure (class 1 evidence) and patients with previous episodes of heart failure (class 2a evidence) [2]. However, these recommendations have yet to be validated in clinical practice. At our vascular pre-assessment clinic, patients scheduled for moderate to high risk vascular surgery undergo targeted echocardiography, in keeping with these recommendations. Our aim was to assess whether using these international guidelines influenced patients' management. MethodsWe retrospectively reviewed our vascular database for all patients undergoing moderate and high risk vascular surgery. We subsequently reviewed all patients who underwent echocardiography following the above guidelines, leading to review of the casenotes, the reason for echocardiography and any changes in patient management. ResultsFour hundred and eighty-seven patients were seen in total over 38 months. Of these, 87 (18%) had pre-operative echocardiography. Eighty-three sets of notes were reviewed in detail. Of these, 51 patients (61%) had echocardiography for NCEPOD recommendations, five (6%) for AHA level 1 recommendations and 27 (31%) for AHA level 2a recommendations.

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