Dose error reduction software in medication safety risk management – optimising the smart infusion pump dosing limits in neonatal intensive care unit prior to implementation

Kuitunen, Sini; Kärkkäinen, Krista; Linden-Lahti, Carita; Schepel, Lotta; Holmström, Anna-Riia

doi:10.1186/s12887-022-03183-8

Table 3 The results of test cases simulating usual doses (n = 32) and test cases including erroneous 10-fold, 5-fold and 2-fold infusion rates (n = 96)

From: Dose error reduction software in medication safety risk management – optimising the smart infusion pump dosing limits in neonatal intensive care unit prior to implementation

	Patient 1.0 kg			Patient 3.5 kg
Fentanyl 5 μg/ml	0.5 μg/kg/h	1 μg/kg/h	2 μg/kg/h	0.5 μg/kg/h	1 μg/kg/h	2 μg/kg/h
Soft upper limit (mL/h)	0.44	0.44	0.44	1.54	1.54	1.54
Usual rate (mL/h)	0.1	0.2	0.4	0.35	0.7	1.4
10-fold rate (mL/h)	1.0^a	2.0^a	4.0^a	3.5^a	7.0^a	14.0^a
5-fold rate (mL/h)	0.5^a	1.0^a	2.0^a	1.75^a	3.5^a	7.0^a
2-fold rate (mL/h)	0.2	0.4	0.8^a	0.7	1.4	2.8^a
Fentanyl 10 μg/ml	0.5 μg/kg/h	1 μg/kg/h	2 μg/kg/h	0.5 μg/kg/h	1 μg/kg/h	2 μg/kg/h
Soft upper limit (mL/h)	0.22	0.22	0.22	0.77	0.77	0.77
Usual rate (mL/h)	0.05	0.1	0.2	0.18	0.35	0.7
10-fold rate (mL/h)	0.5^a	1.0^a	2.0^a	1.8^a	3.5^a	7.0^a
5-fold rate (mL/h)	0.25^a	0.5^a	1.0^a	0.9^a	1.75^a	3.5^a
2-fold rate (mL/h)	0.1	0.2	0.4^a	0.36	0.7	1.4^a
Dopamine 1 mg/ml	2 μg/kg/min	5 μg/kg/min	10 μg/kg/min	2 μg/kg/min	5 μg/kg/min	10 μg/kg/min
Upper soft limit (mL/h)	0.99	0.99	0.99	3.46	3.46	3.46
Usual rate (mL/h)	0.12	0.3	0.6	0.42	1.05	2.1
10-fold rate (mL/h)	1.2^a	3.0^a	6.0^a	4.2^a	10.5^a	21.0^a
5-fold rate (mL/h)	0.6	1.5^a	3.0^a	2.1	5.25^a	10.5^a
2-fold rate (mL/h)	0.24	0.6	1.2^a	0.84	2.1	4.2^a
Dopamine 2 mg/ml	2 μg/kg/min	5 μg/kg/min	10 μg/kg/min	2 μg/kg/min	5 μg/kg/min	10 μg/kg/min
Upper soft limit (mL/h)	0.49	0.49	0.49	1.73	1.73	1.73
Usual rate (mL/h)	0.06	0.15	0.3	0.21	0.53	1.05
10-fold rate (mL/h)	0.6^a	1.5^a	3.0^a	2.1^a	5.3^a	10.5^a
5-fold rate (mL/h)	0.3	0.75^a	1.5^a	1.05	2.65^a	5.25^a
2-fold rate (mL/h)	0.12	0.3	0.6^a	0.42	1.06	2.1^a
Norepinephrine 40 μg/ml	0.1 μg/kg/min	0.2 μg/kg/min	0.4 μg/kg/min	0.1 μg/kg/min	0.2 μg/kg/min	0.4 μg/kg/min
Upper soft limit (mL/h)	0.82	0.82	0.82	2.89	2.89	2.89
Usual rate (mL/h)	0.15	0.3	0.6	0.53	1.05	2,1
10-fold rate (mL/h)	1.5^a	3.,0^a	6.0^a	5.3^a	10.5^a	21.0^a
5-fold rate (mL/h)	0.75	1.5^a	3.0^a	2.65	5.25^a	10.5^a
2-fold rate (mL/h)	0.3	0.6	1.2^a	1.06	2.1	4.2^a
Heparin flush 0.6 IU/ml	0.36 IU/h	0.6 IU/h
Upper soft limit (mL/h)	1.11	1.11
Usual rate (mL/h)	0.6	1.0
10-fold rate (mL/h)	6.0^a	10.0^a
5-fold rate (mL/h)	3.0^a	5.0^a
2-fold rate (mL/h)	1.2^a	2.0^a

The pumps were programmed with the rate corresponding to the usual dose (n = 32) and erroneously with 10-fold, 5-fold and 2-fold infusion rates (n = 96). (^a) identifies the test cases where the soft upper limit triggered an alert (n = 70/96, 73%)

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