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News Release

ISMP Issues Revised and Expanded Guidelines for the Safe Use of Smart Infusion Pumps

Horsham, Pa.—Despite the ability of smart infusion pumps to detect and warn about possible medication errors, healthcare organizations often are not utilizing this important technology to its full potential and serious errors have persisted. The Institute for Safe Medication Practices (ISMP) has published updated guidelines to help healthcare practitioners maximize the intended safety benefits of smart infusion pumps and better position their organizations for bi-directional interoperability with the electronic health record.

“Infusion pump-related errors have frequently occurred due to a failure to engage the dose error-reduction system and the ease with which providers may select the wrong drug library entry or override serious alerts,” says ISMP Director of Consulting Services Michelle Mandrack, MSN, RN. “ISMP has sought input from end users and key stakeholders to identify safety gaps and expand the compendium of expert-and evidence-based best practices available in this area to better protect patients.”

Even when organizations optimize the use of smart infusion pump technology, problems can still exist, often stemming from pumps operating in isolation of other electronic systems and requiring manual programming and documentation by the end user. The ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps outline specific error-reduction strategies to address:

  • Infrastructure
  • Drug Libraries
  • Continuous Quality Improvement (CQI) Data
  • Clinical Workflow
  • Interoperability with the EHR

ISMP published its original smart infusion pump guidelines in 2009. In 2018, ISMP held a second smart infusion pump summit to discuss issues raised by errors reported to the ISMP National Medication Errors Reporting Program (ISMP MERP) and published in the literature since the original guidelines were issued. The second summit was funded by an educational grant from Baxter, B. Braun, BD, ICU Medical, and Ivenix. Participants included organizational end users, smart infusion pump vendors, and representatives of professional and regulatory organizations, who focused on gaining consensus on safe practices that were incorporated into the updated guidelines.

ISMP also has conducted three practitioner surveys to better assess successes, safety concerns, and barriers to the optimization of smart infusion pumps. Identified barriers include significant limitations of pump capabilities, alarm fatigue, persistent deficiencies related to library use and updates, availability of pumps, programming workflow, associated risks with secondary infusions, and pump data analysis.

For a copy of the ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps, visit: Please note that sign-in and/or creation of a free user account may be required for access.

About the Institute for Safe Medication Practices
The Institute for Safe Medication Practices (ISMP) is the only 501c (3) nonprofit organization devoted entirely to preventing medication errors. ISMP is known and respected as the gold standard for medication safety information. For more than 25 years, it also has served as a vital force for progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and drug labeling and packaging. Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and offers a wide range of unique educational programs, tools, and guidelines. In 2020, ISMP formally affiliated with ECRI Institute to create one of the largest healthcare quality and safety entities in the world. As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its life-saving work. Learn more at