Technology has been used to decrease medication errors throughout the medication use process. However, implementation of technology with a prospective approach using human factors techniques to smooth the transitions is not routinely used. Instead, failures in implementation and new errors have occurred. The medication administration process has few double checks in the process and new technology is available to decrease errors. Intravenous medication errors directly reach the patient and are among the most serious medication errors. Smart IV pumps have predefined medication dose limits and their integration with bar code technology may be the ultimate defense for infusion errors. This study proposes to evaluate the implementation of Smart IV pumps and their integration with a bar code medication administration system in an large University Hospital. The technologies have the ability to decrease medication administration errors and change nurses' and other end users' worklife. For that reason, human factors approach with prospective error analysis will be used to evaluate the technology and technology change process; specifically utilizing failure mode and effects analysis(FMEA), work system analysis and technology change surveys to improve implementation. Direct observations, surveys and longitudinal assessment of the Smart IV pump event log data and error reports will provide rich data on IV pump programming errors and provider job and worklife characteristics affected by the change process. This study will provide hospitals without medication administration technology opportunities to assess and change human, medication and organizational factors related to pump programming errors. Valuable information will be gained and shared about the technology change process associated with Smart IV pump implementation and integration with a bar code medication administration system to allow other hospitals to safely and effectively implement these technologies and avert new errors.


The research project is housed in the Center for Quality and Productivity Improvement (CQPI) at the University of Wisconsin–Madison. It is a collaborative project involving various departments and units at the University of Wisconsin-Madison (CQPI, Department of Medicine, Department of Anesthesiology and School of Nursing) and the University of Wisconsin Hospital. The research project is funded by the Agency for Healthcare Research and Quality (AHRQ Grant # 1 UC1 HS 014253-01, PI: Pascale Carayon, Co-PI: Tosha Wetterneck).

Specific aims

• To determine the effect of Smart IV Pump technology implementation and integration with bar code technology, supported by sophisticated human factors techniques, on medication errors.
• To determine the impact of Smart IV Pump technology and the integration with bar code technology on nurses, pharmacists and physicians (end users).
• To describe a human factors prospective error analysis and to qualitatively evaluate its effectiveness on the implementation success of technology in an acute care hospital setting.