Near-infrared spectroscopy monitors: a novel tool for patient safety in the intensive care unit

Medication errors due to adverse incidents with medical devices are a significant contributor to the total number of hospital errors. Unfortunately, there may be no warning when a device fails, and caregivers may not have an opportunity to prevent patient harm as a result. An error of unrecognized interruption of infusions of cardiac medications can cause rapid patient deterioration. In the case presented, near-infrared spectroscopy monitoring alerted caregivers to an otherwise clinically silent error with infused cardiac medications in the intensive care unit and permitted recognition and intervention before patient harm occurred.