The Joint Commission has issued a Sentinel Event Alert to describe actions healthcare organizations can take to reduce the risk of errors caused by the misuse of smart infusion pumps. Such errors are caused by a combination of human and technical risk fac-tors. including fatigue, distraction, and drug library overrides. Many of these errors could be avoided by the correct use of built-in dose error reduction software (DERS). Most healthcare facilities in the US have invested in smart infusion pumps that include DERS, according to The, Joint Commission.
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