Table 3.
Examples of errors with potential harms.
| Error case # | NCC MERP | Type of error | Medication and dose infusing via IV pump | Medical record order | Likelihood of preventability with smart pump technology |
|---|---|---|---|---|---|
| 1 | C | Clamp closed | Cefepime 2g/50mL, 16.7m/hr(observed at 9:49am) | Cefepime 2g/50mL, 16.7m/hr administered at 9:02am | No |
| 2 | C | Clamp closed | Phytonadione(vit K) 10mg/100mL, 50mL/hr(observed at 9:49am | Phytonadione(vit K) 10mg/100mL, 50mL/hr administered at 9:02am | No |
| 3 | C | Right meds programmed in correct channel /pump | 1/2Normal Saline 125mL/h, pump programmed as Normal Saline | 1/2Normal Saline 125mL/h | Yes(with closed loop smart pump) |
| 4 | C | Rate deviation | Normal Saline 5mL/h | Normal Saline 3mL/h | Yes(with closed loop smart pump) |
| 5 | C | Incorrect info on label | Heparin 25,000 unit / 250 mL, 1250units/hr 12.5mL/hr, drug name on a hospital label prepared by nurses was wrong(pharmacy label was correct) | Heparin 25,000 unit / 250 mL, 1250units/hr 12.5mL/hr | No |
| 6 | C | Unauthorized medication | Normal Saline 5mL/h | No order | No |