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5PSQ-112 Hidden harm? Assessing magnitude and costs of intravenous therapy administration errors via smart pump reports
  1. R Aljaber1,
  2. J Waterson2
  1. 1King Faisal Specialist Hospital and Research Center, Pharmaceutical Care Division, Riyadh, Saudi Arabia
  2. 2Becton-Dickinson and Company Llc, Medication Management Solutions, Dubai, United Arab Emirates


Background and importance Most reviews of intravenous therapy administration error have been undertaken in critical care. In our study wireless pumps gave access to smart pump therapy library log data from lower acuity areas of care such as oncology infusion centres, labour and delivery, and medical–surgical wards. Analysis of the magnitude and costs of errors in these areas has previously been lacking.

Aim and objectives To establish likely incidence of moderate and catastrophic intravenous therapy administration error via ‘good catch’ data in areas outside of critical care, to identify and classify the medications involved and to estimate likely costs of these errors.

Material and methods A review of 3 025 414 dose error reduction system protected infusions from adult units outside of critical care across the Middle East for the volume of averted dose/duration errors was undertaken, and a recognised grading of ‘moderate’ and ‘catastrophic’1 was applied. Projected savings from errors prevented was assessed against current intensive care unit (ICU) bed and medical ward costs in the Gulf region2 and an average length of stay extension identified from the current literature.1

Results Catastrophic errors averted would cost, conservatively, US$114 503 per 10 000 infusions delivered. The average 1000 bed hospital delivery ≈750 000 infusions per annum.

Abstract 5PSQ-112 Table 1

Conclusion and relevance The study identified an incidence rate above those in many published studies; this may be because we ‘cast the net wider’ and because in the areas studied there was limited clinician experience of administration of some of the medications. Competency is difficult to maintain with limited exposure to a task. The presence of insulin, potassium preparations, and cytotoxics in our results is in line with other studies. The cost savings indicate the potential value of smart intravenous technology being deployed in every part of the hospital

References and/or acknowledgements 1. Manrique-Rodríguez, et al. Implementing smart pump technology in a pediatric intensive care unit: a cost-effective approach. Int J Med Inform 2014;83(2):99–105.

2. Khan, et al. Survival and estimation of direct medical costs of hospitalized COVID-19 patients in the Kingdom of Saudi Arabia. Int J Environ Res Public Health 2020;17(20):7458.

Conflict of interest Corporate sponsored research or other substantive relationships: advisory board for Becton Dickinson.

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