Many medication errors can be prevented through safe medication practices; however, sometimes these errors – including those involving “smart” infusion pumps – are caused by a combination of human and technical risk factors.
A new Sentinel Event Alert from The Joint Commission, “Optimizing smart infusion pump safety with DERS,” describes how built-in dose error reduction software (DERS) can improve patient safety. The alert provides recommended safety actions health care organizations can take to reduce the risks of errors caused by the misuse of smart infusion pumps.
Smart infusion pumps with DERS are designed to reduce errors by keeping medication infusions within generally accepted ranges. The capability of DERS to store drug library information – such as hospital-defined dose/concentration/rate limits and clinical advisories – helps to avert errors and warn clinicians about potentially unsafe drug therapy.
With understanding that the capabilities of smart infusion pumps and DERS vary within each organization, The Joint Commission suggests the following general actions:
In addition, The Joint Commission has several hospital standards and elements of performance (EPs) that address medication administration safety and support processes, including performance improvement.
The Sentinel Event Alert is available on The Joint Commission website. It may be reproduced if credited to The Joint Commission.
 American Society of Health-System Pharmacists. ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacists. 2018;75(19):1493-1517.
 Institute for Safe Medication Practices. Guidelines for optimizing safe implementation and use of smart infusion pumps. 2020.
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