Preventing Dosing Errors in High-Risk Infusions Due to Titration Programming
IV Pump News December 14, 2017
Baxter Healthcare Corporation affiliated authors conducted a study of harmful dosing changes caused by titration miss-programming. The study was presented at the 2017 ASHP Midyear Clinical Meeting and Exhibition.
The study found that opportunities for pump programming errors are created by titrations of high-alert drugs after the infusions are started. Titration miss-programming, especially of high-risk infusions, can lead to harmful dosing error that can be missed because they fall within the “soft” dosing range of drug library dosing range limits. Normal dosing limits on smart pump drug libraries or EMR systems may not be protected from titration programming.
The authors of the study recommend that infusion systems should be designed with safety parameters for titration programming such as built-in titration error prevention, like with the Sigma Spectrum Infusion System. It is also recommended that titratable medication orders should include the starting dose, titration dose increments, titration timeframes, maximum dose, and clinical endpoints in order to provide maximum safety and prevent errors.
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