Table 1.

Identified Error Types and Subtypes Associated with Smart Infusion Pumps

Error Category	Error Type (NCC MERP Taxonomy Number)	Error Subtype	Potential Causes (NCC MERP Taxonomy Number)
Undocumented Errors (E1.0)	Undocumented verbal orders for medications administered (E1.1)		Communication (81) Human Factors (87) System-related (90)
	Unauthorized fluid/med - no order for it in the system (E1.2)		Communication (81) Human Factors (87) System-related (90)
Drug Library Errors (E2.0)	Wrong drug library selected (E2.1)		Communication (81) Name Confusion (83) Human Factors (87) Packaging/Design (89) System-related (90)
	Drug library insufficient (E2.2)	Medication not in drug library (E2.2.1)	Packaging/Design (89) System-related (90)
		Medication concentration not in the drug library (E2.2.2)
		Drug library does not match hospital policies (E2.2.3)
		Units in drug library don’t match orders (e.g., orders used mg, limits in gm) (E2.2.4)
	Bypassing an available drug library e.g., Basic infusion selected instead of a drug-specific library (E2.3)		Human Factors (87) Packaging/Design (89) System-related (90)
Programming Errors (E3.0)	Wrong concentration programmed (E3.1) 70.3 Wrong Strength/Concentration		Communication (81) Name Confusion (83) Human Factors (87) Packaging/Design (89) System-related (90)
	Wrong volume programmed (E3.2) 70.2 Improper Dose	VTBI (Volume to Be Infused) not programmed (E3.2.1)	Communication (81) Name Confusion (83) Human Factors (87) Packaging/Design (89) System-related (90)
		Programmed extra volume for extra fluid in bag/priming (E3.2.2)
		Wrong VTBI programmed (doesn’t match order) (E3.2.3)
	Wrong dose programmed (E3.3) 70.2 Improper Dose	Dose infused doesn’t match the order (E3.3.1)	Communication (81) Name Confusion (83) Human Factors (87) Packaging/Design (89) System-related (90)
		Non-titratable medication order - medication dose was titrated (E3.3.2)
		Titratable med order - dose was not titrated as ordered (E3.3.3)
		Extra doses administered (intermittent medication administration) (E3.3.4)
		Using drug calculation to provide dose outside of library - drug calculator workaround (E3.3.5)
		Programming with incorrect units (e.g. mg instead of gm) (E3.3.6)
		Wrong 4-hour dose limit *applicable to PCAs only (E3.3.7)
		Accidentally adding or subtracting an extra digit (e.g., “factor of 10” error) (E3.3.8)
		Drugs dosed at decimal level (e.g. 0.01 mg/mL) (E3.3.9)
	Wrong rate programmed (E3.4) 70.8 Wrong Rate	Rate of infusion doesn’t match the order (E3.4.1)	Communication (81) Name Confusion (83) Human Factors (87) Packaging/Design (89) System-related (90)
		Providing bolus by increasing rate (E3.4.2)
		Infusion as bolus infusion ends and the pump defaults to historical infusion parameters (E3.4.3)
	Wrong patient weight programmed (E3.5)	Wrong patient’s weight entered (E3.5.1)	Communication (81) Human Factors (87) Packaging/Design (89) System-related (90)
		2.2x weight error (patient’s weight in lbs. entered instead of kg) (E3.5.2)
	Programming errors- other (E3.6)		Communication (81) Name Confusion (83) Human Factors (87) Packaging/Design (89) System-related (90)
Administration Errors (E4.0)	Administered to the wrong patient (E4.1) 70.11 Wrong Patient		Communication (81) Human Factors (87) Packaging/Design (89) System-related (90)
	Administered via the wrong route (e.g., intrathecal vs intravenous) (E4.2) 70.7 Wrong Route		Communication (81) Human Factors (87) Packaging/Design (89) System-related (90)
	Wrong administration technique (E4.3) 70.6 Wrong Technique		Communication (81) Human Factors (87) Packaging/Design (89) System-related (90)
	Not administered - omitted or missed medication dose (e.g., no medication was given an ordered time) (E4.4) 70.1 Dose Omission		Communication (81) Human Factors (87) System-related (90)
	Administered the wrong drug (E4.5) 70.4 Wrong Drug		Communication (81) Name Confusion (83) Human Factors (87) Packaging/Design (89) System-related (90)
Ancillary Equipment Errors (E5.0)	Switched lines; wrong line running through pump (E5.1)		Human Factors (87) Packaging/Design (89)
	Wrong syringe size (E5.2)		Packaging/Design (89; 89.3.2)

Abbreviations: VTBI, volume to be infused; PCA, patient-controlled analgesia; EHR, electronic health record.