Creating a Drug Library for Zero Continuous Infusion Errors in a Paediatric Intensive Care Unit: A Quality...

Medication errors, particularly involving continuous infusions in paediatric intensive care units (PICUs), pose significant risks to patient safety. This quality improvement initiative was prompted by a sentinel adverse event where a paediatric patient received a ketamine infusion at mg/kg/min instead of μg/kg/min, resulting in a dose over 1000 times higher than intended for over 16 h.

The study aimed to evaluate a systems-based solution to reduce continuous infusion errors, focusing on improving patient safety through a multidisciplinary approach, enhancing staff compliance and assessing satisfaction and perceived safety improvements.

A multidisciplinary team employed root cause analysis (RCA) and human factors engineering (HFE) principles to implement interventions, including procuring 150 smart infusion pumps with a customized drug library, aligning it with the EPIC electronic medical record (EMR) system, standardizing medication preparations and conducting extensive staff training. Implementation followed a Plan-Do-Check-Act (PDCA) cycle, starting with a pilot and scaling to the full 25-bed PICU. Following implementation, two minor incidents related to medication concentration changes occurred in October 2024. These were effectively addressed through reinforced education, the introduction of double-checking policies and hands-on simulation training. Since then, no further incidents have been reported from October 2024 to 1 January 2026. Outcomes were assessed using surveys conducted at 3- and 6-month post-implementation, along with rounds by the shift in-charge, biomedical engineering and nurse educator, and independent double-checking at initiation of a new infusion, syringe replacements and shift endorsements.

The initiative achieved zero incidents from October 2024 to 1 January 2026, with compliance improving markedly. Surveys at 3 and 6 months showed over 95% staff satisfaction and perceived safety improvements. The project expanded to the emergency department and five subspecialty wards, demonstrating scalability.

The intervention successfully minimized continuous infusion errors, fostering a high-reliability culture committed to zero harm. To sustain these gains, we recommend ongoing education, adherence to double-checking protocols and EMR enhancements. Future research should include multicentre evaluations and longer-term monitoring.

This scalable model demonstrates how smart pumps, EMR integration and multidisciplinary training can significantly reduce continuous infusion errors in PICUs, enhancing safety for vulnerable paediatric patients and providing a framework for adoption in other high-risk settings like emergency departments and subspecialty wards.