This is a CHI+MED paper which can be downloaded as a PDF from the link below.
Lee, P. T., Thompson, F., & Thimbleby, H. (2012). Analysis of infusion pump error logs and their significance for health care. British Journal of Nursing (Intravenous Supplement), 21(8), S12-S20.
Infusion therapy is one of the largest practised therapies in any healthcare organisation, and infusion pumps are used to deliver millions of infusions every year in the NHS. The aircraft industry downloads information from ‘black boxes’ to help design better systems and reduce risk; however, the same cannot be said about error logs and data logs from infusion pumps. This study downloaded and analysed approximately 360000 hours of infusion pump error logs from 131 infusion pumps used for up to 2 years in one large acute hospital. Staff had to manage 260129 alarms; this accounted for approximately 5% of total infusion time, costing about £1000 per pump per year. This paper describes many such insights, including numerous technical errors, propensity for certain alarms in clinical conditions, logistical issues and how infrastructure problems can lead to an increase in alarm conditions. Routine use of error log analysis, combined with appropriate management of pumps to help identify improved device design, use and application is recommended.