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Keypad design of IV pumps can cause dosing errors

Patient Safety Monitor Alert, August 13, 2004

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The keypad design on some IV pumps can lead to dangerous dosing errors, warns the Institute for Safe Medication Practices (ISMP).

The ISMP describes several ten-fold dosing errors that occurred after nurses mistakenly pressed the "zero" key instead of the decimal point key when programming the pump.

The errors occurred because the keys are adjacent to one another on the keypad on certain IV pumps, the ISMP reports.

"If your pumps possess this design flaw, alert staff to the potential for errors," the ISMP recommends. In addition, organizations should:

>> require a second person to double-check the programmed dose for all high-alert medications, such as insulin, morphine, heparin, potassium chloride, and warfarin

>> use "smart pumps" that can recognize preset dose limits and alert staff to dosing errors before the infusion begins

The JCAHO promotes infusion pump safety through its 2004 National Patient Safety Goals, which require organizations to ensure free-flow protection on all general use and patient controlled analgesia pumps.

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