Medical device errors in intensive care units and patient safety: a systematic review

Medical device errors in Intensive Care Units (ICUs) position a critical threat to patient safety due to the complexity of devices, high patient alertness, and demanding clinical situations. Despite rising support on medical technologies, evidence on the nature of causes and prevention of device-oriented errors in ICUs remains fragmented.

The PRISMA guidelines were followed throughout the systematic review, and the review was registered in PROSPERO (CRD42023424716). Studies published between 2010 and 2025 were accounted through 17 databases. The studies on medical device errors in adult, pediatric, and neonatal ICUs were encompassed, and the outcomes were synthesized qualitatively.

Seventy-two studies were covered and infusion pumps, syringe pumps, ventilators, and monitoring equipments were majorly associated with medical device errors. Errors were primarily related with human factors, device design flaws, and system failures. Infusion pump errors occurred in 60% of infusion initiations (80,209/133,601), while 89% of arrhythmia alarms were false positive among 2.5 million monitor alerts recorded in a cohort of 461 ICU patients.

Medical device errors in ICUs are multifactorial. Effective prevention requires integrated approaches encompassing human factors engineering, focused training, improved device design, and a strong resilient patient safety culture.