The Joint Commission issues Sentinel Event Alert on smart infusion pump safety

Editor's Note

The Joint Commission, on April 14, issued Sentinel Event Alert 63: Optimizing smart infusion pump safety with DERS [dose error reduction software].

Though smart infusion pumps combine computer technology and drug libraries (stored in DERS) to limit the potential for dosing errors, errors still occur each year. Bypassing the smart infusion pump or the drug library accounted for about 10% of errors or policy violations related to infusion administration in one study.

The Sentinel Event Alert describes actions healthcare organizations can take to reduce the risk of errors caused by the misuse of smart infusion pumps, especially errors that can be avoided by the optimal use of DERS.