Smart pumps improve medication safety but increase alert burden in neonatal care

Melton KR, Timmons K, Walsh KE, Meinzen-Derr JK, Kirkendall E. Smart pumps improve medication safety but increase alert burden in neonatal care. BMC Med Inform Decis Mak. Nov 7, 2019;19(1):213.

Smart pumps have been adopted as one approach to preventing medication errors, but less is known about their use in pediatric populations and contribution to NICU alert fatigue. This study examined NICU smart pump records from 2014 to 2016 and found that pump alerts do not contribute significantly to overall alert burden in the NICU, and alerts tended to cluster around specific patients and medications (such as fentanyl, insulin and vasopressin). The study also identified 160 attempts to exceed the programmed dosing limit; while these represented a small number of violations over the entirety of the study period, the attempts involved high-risk medications (including fentanyl, insulin, and morphine) and doses programmed at 5- to 24-times the maximum dose which could result in significant adverse patient outcomes.

PubMed citation

Available at