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The Joint Commission issues Sentinel Event Alert on optimizing medication safety with smart infusion pumps

The Joint Commission

Many medication errors can be prevented through safe medication practices;[1] 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.[2]

With understanding that the capabilities of smart infusion pumps and DERS vary within each organization, The Joint Commission suggests the following general actions:

  • Identify a multidisciplinary project team or department responsible for smart infusion pump interoperability, including DERS, the oversight of drug library revisions or additions, infusion protocols, smart infusion pump maintenance and related issues.
  • Define a process to create, test, regularly engage with, and maintain a drug library.
  • Train and assess competency of all clinical staff, including nurses and other clinicians who travel to various care settings.
  • Make the optimal use of DERS expected practice.
  • Monitor alerts, overrides, equipment or software recalls, and adverse event and close call reports.
  • If your organization has the capability, connect smart infusion pump fleet with electronic health record (EHR) system.
  • Identify and address human and environmental factors that may contribute to smart infusion pump programming errors.
  • Keep the smart pump fleet safe from security threats and during downtime.

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.

[1] 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.

[2] Institute for Safe Medication Practices. Guidelines for optimizing safe implementation and use of smart infusion pumps. 2020.



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