Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS

Editor's Note: For over two decades, The Joint Commission has developed and disseminated Sentinel Event Alerts (SEAs). SEAs identify specific types of adverse events and high-risk conditions, describe their underlying causes, and recommend steps to reduce risk and prevent future occurrences. Health care organizations should consider the information in SEAs when designing or redesigning processes, including specific suggestions contained in the alerts to mitigate risks. Recently, The Joint Commission decided that co-publishing SEAs in the Journal would help expand dissemination efforts by reaching beyond health care organizations to the broader quality and safety community, including researchers and policymakers. In this issue, we are proud to publish Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS (dose error reduction software). The SEA describes actions health care organizations can take to reduce the risk of errors caused by the misuse of smart infusion pumps, especially errors that can be avoided by the optimal use of DERS. We will co-publish future SEAs that we think would be of interest to the Journal's audience. We hope you enjoy this new addition to the Journal.