Medication errors are the most significant cause of medical injuries, representing 19.4% of all adverse events1. Intravenous (IV) infusions have been identified as frequent contributors to medication errors, and the injuries that result from them2, 3, 4. General infusion pumps were designed to improve accuracy and continuity of IV infusions by allowing nurses to program an hourly rate and volume. However, studies have shown that these devices are involved in 35-60% of the estimated 770,000 Adverse Drug Events (ADEs) that occur
each year5,6,7,8.

Most ADEs associated with IV infusion devices occur as a result of nurses manually inputting incorrect settings into the pump9,5,8. The most common infusion errors include unit errors, multiple of ten errors, miscalculations and push-button mistakes10. For example, fatal errors have occurred as a result of decimal entry errors when programming infusion pumps (e.g., programming morphine at 90 ml/hr instead of 9.0 ml/hr, causing a 10 fold overdose7). Thus, although infusion pumps have revolutionized the way nurses deliver intravenous therapy, they have also led to ADEs6,7.