A woman who'd recently undergone cesarean section went to the ED with dyspnea. The physician, believing she'd developed a pulmonary embolism, prescribed a heparin bolus of 5,000 units I.V. followed by a heparin infusion at 1,000 units/hour. After administering the bolus dose, a nurse misprogrammed the infusion pump to infuse 1,000 mL/hour, not 1,000 units/hour. In less than an hour, the patient received more than 17,000 units of heparin.

The infusion was running via a "smart" pump with dosing limits for heparin, so the pump should have alerted the programming error before the infusion was started. But the nurse had chosen to bypass the dose-checking feature and used the pump in standard mode. The patient's activated partial thromboplastin time (aPTT) reached 240 seconds (normal, 20 to 35 seconds), but she didn't experience serious bleeding.

Smart pumps are designed to recall dose limits and other advisories in a facility's drug library; the information then appears during pump programming and warns clinicians about potential unsafe drug therapy.1 Having to take extra steps to use the mode that accesses the drug library can discourage compliance. Smart pumps that are designed to make overriding the drug library more difficult are more desirable.

A culture of safety is also necessary to ensure compliance using smart pump technology and evaluating clinical alerts. Facilities can nurture compliance with these actions:

* analyzing pump logs and making necessary adjustments to the drug library

* evaluating all overrides

* publicizing "good catches"

* conducting focus groups and satisfaction surveys to get feedback from nurses and other users.

Using the dose-checking feature of smart pumps shouldn't be optional, and you shouldn't bypass alerts from the system without serious consideration of the risk. For every error like the one described here, smart pump technology has prevented many more. Some day soon, failure to use this technology as intended may be considered below the standard of care.

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