Infusion Pump Errors: An Unseen Peril at the Bedside
There’s a healthcare crisis plaguing today’s hospitals and patients, yet few seem willing to address it. Hiding in plain sight at the bedside of nearly 90% of patients within hospitals are IV pumps, and these critical devices are responsible for numerous medication errors reported to the FDA each year. Some of these errors have been deadly, and many could have been prevented.
Between 2015 and 2017, the FDA reported more than 23,000 malfunctions and injuries attributed to the three most commonly used large-volume pumps. That’s equivalent to 23 malfunctions and injuries every day that are associated with a medical device intended to safely deliver IV drugs. Of the approximately 1.5 million adverse drug events reported to the FDA each year, 54% of those are related to infusion pump errors. And a sobering 61% of those adverse events reported are serious or life threatening.1,2
Born from a cocktail of industry apathy and lagging technology, this crisis has gone unaddressed for too long. These numbers are not only frightening—they’re also unacceptable. The outdated platforms in which pumps operate have not evolved to meet the challenges of complex patients or advanced pharmaceuticals. In an era where disruptive technology is impacting nearly every aspect of our lives—from our smart watches to smart homes—infusion pumps built on legacy technology could be harming patients every day within our hospitals.
This inaction has consequences and continues to contribute to the national patient safety problem. Why hasn’t new technology been developed to address these unnecessary malfunctions and injuries? What’s more: Why is no one talking about it? When there’s an airbag recall, for example, it’s seemingly impossible to escape the news. It’s everywhere. Yet, infusion errors are unfortunately, more common, they’re more frequent and they can be more deadly. Why don’t we read about these errors as frequently as we do airbag recall-related injuries?
Let’s take a look at an airbag recall for reference. A Takata airbag was recalled in 42 million cars in the United States starting in 2013. To date, the airbags have caused approximately 180 injuries and 20 deaths. IV infusion pump recalls reported to the FDA between 2005 and 2009 alone were responsible for 710 deaths and approximately 56,000 injuries, according to AAMI. What’s the disconnect here? Why don’t we care?
Change is long overdue and there are great nonprofit organizations leading the charge. The nonprofit watchdog Leapfrog Group recently added a new measure to its hospital patient safety grades to assess how well the hospital prevents and identifies medication errors. The independent patient-safety organization ECRI once again ranked medication errors related to infusion pumps as a top technology hazard for 2019. The Institute for Safe Medication Practices (ISMP), an organization entirely devoted to preventing medication errors, facilitated a national summit in spring 2018 to create guidelines on the safe implementation and use of smart infusion pumps. And for the past several years, The AAMI Foundation has led a national coalition on infusion therapy safety and safe use of complex healthcare technology.
It’s heartening to know so many organizations are working to provide transparency on IV medication errors and develop guidelines for IV pumps. However, support is needed from all leaders to demand improvements in this area. As long as IV pumps continue to rely on outdated technology, patients are at risk. We, as an industry, must answer the call for safer infusion pumps and fewer adverse events. Our patients are counting on us.
References
- Kaushal R., Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114–20.
- Vanderveen TM. (2005). “Averting Highest-Risk Errors Is the First Priority.” Patient Safety & Quality Healthcare. Retrieved from: http://psqh.com/mayjun05/averting.html.
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