Medication errors account for almost 20% of all medical injuries. Administration is the stage of the medication process most vulnerable to error, and the intravenous (IV) route of drug administration often results in the most serious patient injuries. IV infusion errors, which involve high-risk medications delivered directly into a patient’s bloodstream with an infusion pump, have been identified as having the greatest potential for patient harm.

An understanding of the function, components, and use of medication pumps is essential for the anesthesia technician. Medication pumps are commonly used in the operating room (OR), obstetric suite (OB), and postanesthesia care unit (PACU). Infused medications include vasopressors, vasodilators, inotropes, antibiotics, chemotherapy medications, local anesthetics, sedatives, hypnotics, opioids, and muscle relaxants. Advances in the technology of medication pumps have introduced many new features. Today’s “smart pumps” have computer processors to provide decision support and fail-safe functions to improve patient safety. The anesthesia technician will be called upon to deliver pumps to the OR suite or off-site location and should be able to properly set up each device used in the facility. While the infusion pump is in use, the technician may need to troubleshoot alarms and nonfunctioning devices and be able to determine if the device needs replacement or service.

Because the majority of anesthesia technicians will be involved in pump setup and troubleshooting, they should attend available opportunities for in-service training, particularly when new pumps are introduced into the department. The individual vendors are a great source of information and instruction on the use and maintenance of the medication pumps used at your facility. In addition, anesthesia technicians will be involved in the maintenance of pump units stored in the department. The anesthesia technician must ensure that “smart pumps” are updated on a predetermined basis by the pharmacy and that they meet all standards set by governing entities. The technician should be sure that after pumps are used, they are returned to the workroom and cleaned according to the protocol at the facility.

A major goal in the campaign to improve medication safety is to develop safer systems for the monitoring and delivery of drugs. IV medications administered through a pump must be delivered with precision due to the nature of the medications and the IV route of administration. IV administration results in a more rapid onset of drug effect; therefore, harmful side effects or the effects of drug toxicity may be more severe than when the same medication is administered orally. In addition, medication pumps deliver continuous infusions of medications. Thus, any error in dosing or formulation can be compounded over time. These issues effectively reduce the safety margin when medications are administered by IV infusion.

The Joint Commission has noted that infusion pumps were frequently involved in medication errors that lead to serious patient injury. Experts reviewing these incidents have identified several human and mechanical errors. One of the most common problems was the use of pumps that do not provide protection from the free flow of IV fluid/medication into the patient. In addition, problems can occur when the wrong drug or concentration is administered, or the wrong rate is set. To address these issues, manufacturers of medication pumps have developed
a number of innovations. For example, medication “smart pumps” were introduced in 2002 by Alaris Medical Systems, Inc. These computerized pumps for volume infusion and medication delivery utilize traditional infusion pump technology, while adding control over medication delivery based on predetermined clinical guidelines. Smart pump design improves medication safety by making it harder for the clinician to inadvertently enter the wrong information when programming the pump. This class of pumps utilizes drug libraries that include dosage parameters and alerts, requiring the clinician to intercede if the medication to be delivered is outside the dose recommended by the pharmacy and clinical advisory teams. Prior to smart pumps, most hospitals did not have drug dosing limits built into medication pumps, and drug information on high and low limits for IV medications was not available at the point of care.

Other safety features of newer generation medication pumps include dosing alerts, continuously updated drug libraries, and treatment unit-specific programming. Requiring the provider to actively override alerts improves patient safety while allowing for flexibility in treating unique patient situations. For example, the pump may alert the provider that the programmed medication should be administered through a central venous line. The physician can override the alert based on clinical circumstances. Linking the smart pump to a computer network can allow drug library information to be automatically uploaded to the device as changes in practice, medication libraries, alert or dosing limits, or use of medications and practice guidelines occur. Medication pumps can be configured to fit the needs of the patients according to the unit in which they are receiving care, such as the OR, PACU, and the adult, pediatric, and neonatal ICUs. Alert limits and drug libraries can be tailored for each specific treatment unit. When a patient is transferred to a different treatment unit, care must be taken to exchange the pump for one that is appropriate to the new treatment unit, or, if possible, reset the pump for the new treatment unit. For example, when a patient is transferred to the OR from the floor, any medication pumps may need to be reset to OR settings to allow the anesthesia provider to access drug libraries and utilize alarm parameters that are appropriate to the OR and delivery of medications by anesthesia personnel. New technologies incorporate systems that will allow a single pump to follow the patients throughout their hospital stay by entering the hospital department into the “smart pump” via the data screen. The pump will change the drug library and parameters particular to that department’s protocols.

An additional safety feature of modern medication pumps is the ability to continuously record similar to an airplane “black box.” The pump software allows the data to be retrieved for quality improvement purposes. This information can be used to review programming errors or identify treatment processes that could be improved and was unavailable prior to the introduction of smart pumps.

One critical error that cannot be detected by the pump is the attachment of the wrong medication or concentration to the pump. For example, a provider wants to administer a normal saline and an epinephrine infusion. The pump is properly programmed to deliver a normal saline infusion at 100 mL/hr and epinephrine at 0.15 µg/kg/min; however, the bag of epinephrine is inadvertently attached to the tubing going to the pump for the normal saline and the normal saline is attached to the pump for the epinephrine. This situation would lead to a severe reaction in the patient due to an overdose of epinephrine.

Manufacturers produce medication pumps that meet the needs of a broad range of settings including those that deliver medications in IV