MEDICATION ERRORS: The devil's in the decimal

February 2004 
Volume 34  Number 2
Pages 17 - 17
  PDF Version Available!


  • Testing infusion pumps for free-flow


  • Figure. No Caption A...

    A nurse programmed an infusion pump to deliver an infant's total parenteral nutrition at 13.0 ml/hour, but the decimal point key didn't engage and the pump was set to deliver 130 ml/hour. The infant received the solution at the incorrect rate for about an hour before someone discovered the error. Fortunately, he wasn't permanently harmed.

    Setting the infusion pump at “13” rather than “13.0” would have prevented this error. Another alternative is a “smart” pump that uses a computer to help prevent wrong-dose and wrong-infusion-rate errors. With a smart pump, you set individualized dose limits for the patient or the disorder and an alert signals if the limits are exceeded. Another safeguard is to double-check pump settings before you leave the patient's bedside or ask another nurse to perform an independent ...

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