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Updated: Jan 23, 2026
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Published on: July 13, 2019
Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting
Sonia J Pinkney1, Mark Fan2, Christine Koczmara3
1HumanEra, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
Objectives:
Assess interventions' impact on preventing IV infusion identification and disconnection mix-ups.
Design:
Experimental study with repeated measures design.
Setting:
High fidelity simulated adult ICU.
Subjects:
Forty critical care nurses.
Interventions:
Participants had to correctly identify infusions and disconnect an infusion in four different conditions: baseline (current practice); line labels/organizers; smart pump; and light-linking system.
Measurements And Main Results:
Participants identified infusions with significantly fewer errors when using line labels/organizers (0; 0%) than in the baseline (12; 7.7%) and smart pump conditions (10; 6.4%) (p < 0.01). The light-linking system did not significantly affect identification errors (5; 3.2%) compared with the other conditions. Participants were significantly faster identifying infusions when using line labels/organizers (0:31) than in the baseline (1:20), smart pump (1:29), and light-linking (1:22) conditions (p < 0.001). When disconnecting an infusion, there was no significant difference in errors between conditions, but participants were significantly slower when using the smart pump than all other conditions (p < 0.001).
Conclusions:
The results suggest that line labels/organizers may increase infusion identification accuracy and efficiency.
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