On the market for years now, so-called smart infusion pumps are nearly ubiquitous in acute care settings across the country today, representing a big step forward in infusion safety. However, errors still can occur. The Joint Commission (TJC) notes errors usually are attributable to a combination of human and technical risk factors.

In a recent Sentinel Event Alert, TJC stressed that an important way to optimize safety when using these pumps is by using smart pumps along with built-in dose-error reduction software (DERS).1

What is DERS, and how does it work to boost safety? Michelle Mandrack, MSN, RN, director of consulting services at the Institute for Safe Medication Practices (ISMP), says by using DERS, staff can preload high and low limits around the different parameters of infusion orders. “The parameters could pertain to the dose itself, the rate, the concentration, or how long [it should take] for infusion to take place,” she explains.

Generally, these parameters are set in a drug library that works with a hospital’s fleet of smart infusion pumps. If a clinician accidentally enters an amount or concentration of a medication outside the limits set in the drug library, the smart pump will communicate a hard stop to the clinician, indicating the infusion cannot go forward as entered. Alternately, the instructions in the library may dictate a soft stop in which the limits can be overridden in that circumstance, but the clinician is alerted to double-check the order. In either case, most dosing or data entry errors are prevented.

Considering the importance of the information in the drug library, TJC advises hospitals to designate a multidisciplinary team or department to oversee the library and the infusion pump interoperability. The ISMP agrees with this recommendation.2 “This key committee would [include] pharmacists who are very familiar with building drug libraries. It would [include] some nurse representation, maybe a biomedical engineer, as well as some ad hoc prescribers,” Mandrack says.

These multidisciplinary panels will be comprised differently, depending on the organization involved. Regardless, Mandrack says some physician representation is essential. Not only is their input helpful in building the drug library, but they could help the organization standardize prescribing styles.

For example, Mandrack says the way an ED physician orders an infusion might differ from the way the same infusion is ordered on a med-surg floor or in the ICU. Different providers may be accustomed to using different nomenclatures, weights, and unit measures, but facilities would want these standardized and clarified in the library.

Also, depending on the part of the library that is under construction or revision, leaders should include prescribers involved in that area. “If you are building the oncology drug library, then of course you would have an oncology prescriber involved,” Mandrack offers. “Then, if you have changes to that oncology drug library, depending on what they are, you would want to get input from the prescriber perspective as well.”

Connect with EMR

In addition to assembling a multidisciplinary team to oversee smart infusion pumps, TJC recommends hospitals define a process for creating, testing, and maintaining the drug library. The accrediting agency suggests hospitals train and assess the competency of all clinical staff to use smart infusion pumps and make the use of DERS an expected practice.

Further, the agency asks hospitals to take steps to connect their smart pump fleets with their electronic medical record (EMR) systems. This is a relatively new capability, but one that takes safety to another level.

“Then, a physician order for an infusion can be reviewed by a pharmacist, and then automatically go to the pump through bar coding, [where it] populates the screen so the nurse doesn’t have to manually enter all of the components of the order,” Mandrack says. “The pump can then send that information, when it is pumping, back to the EMR automatically.”

Such interoperability can reduce any data entry errors, but Mandrack notes it does take time for nurses to acclimate. “This [process] may not seem intuitive for the nurses because they’ve got to take a scan of the patient’s barcode. They then have to scan their own [hospital] badge. They then have to scan the medication container, usually an infusion label. Finally, they’ve got to scan the pump,” she explains. “Nurses tell us that it probably takes a little bit longer, but they incorporate it into their workflow. It becomes like a new pattern, and there is that safety value for sure.”

TJC adds hospitals should put mechanisms in place to monitor pump alerts, overrides, equipment or software recalls, and reports of adverse events or close calls. Further, when programming errors occur, TJC states those events need to be analyzed to determine what human and environmental factors may have contributed. Finally, the accrediting agency notes hospitals need to keep their smart pump fleets safe from security threats when they are not in use. 


  1. The Joint Commission. Optimizing smart infusion pump safety with DERS. Sentinel Event Alert. April 14, 2021.
  2. Institute for Safe Medication Practices. Guidelines for optimizing safe implementation and use of smart infusion pumps. Feb. 10, 2020.