The Pump That Delivered Ten Times the Dose

A clinician programs an IV infusion pump. A decimal slip, a wrong unit, or an unclamped secondary line means the pump delivers far more — or far less — than intended. The display faithfully confirms the number that was entered, not the dose actually reaching the patient.

Infusion pumps are among the most error-prone devices at the bedside. From 2005 to 2009 the FDA received roughly 56,000 adverse-event reports tied to infusion pumps, prompting 87 recalls (14 of them Class I — able to cause serious harm or death). FDA attributes many events to device design and user-interface issues, not just slips of the hand — which is exactly why the same order is dangerous across different pumps.

1. The order is dose-based; the pump wants a rate — the units have to be converted in the nurse's head.
2. A decimal or field slip enters 50 where 5 was meant, or mg where mcg was meant.
3. Smart-pump drug-library limits are off, in 'basic mode', or overridden under time pressure.
4. The pump runs exactly as programmed; the screen shows the entered number and looks normal.
5. The error surfaces late — as an occlusion alarm, an empty bag, or a change in the patient's condition.

~56,000 FDA adverse-event reports over 2005–2009 (see stats); infusion hazards remain on ECRI's current Top 10.

Over- or under-dose. Shown through the pump display, the occlusion-alarm bar, and an empty IV bag — never the patient.