Errors occurring during blood pressure monitoring
Pulse rhythm
Equipments Used To Measure Blood Pressure
Pharmaceutical Poisoning: Potential Scenarios
Drug Accumulation During Multiple Dosing: Intermittent IV Infusions
Drug Accumulation During Multiple Dosing: Repetitive IV Injections
You might also read
Articles linked to this work by shared authors, journal, and citation graph.
Updated: May 31, 2026

Improving IV Insulin Administration in a Community Hospital
Published on: June 11, 2012
Brenda Abena Nyarko1,2, Cidalia J Vital1,2,2, Karen K Giuliano1,2,2
1Elaine Marieb Center for Nursing and Engineering Innovation, University of Massachusetts Amherst, Elaine Marieb College of Nursing, University of Massachusetts Amherst, MA, USA.
This study examined how often intravenous smart pumps trigger alarms in a large hospital. Researchers found that these devices generate millions of alerts, with specific types like downstream occlusions occurring most frequently. Pediatric and neonatal units face the highest burden of alarms per infusion, which may lead to staff fatigue and safety risks.
Area of Science:
Background:
No prior work had resolved the full scope of alarm frequency across diverse hospital units. That uncertainty drove the need for a comprehensive assessment of device alerts. Prior research has shown that constant noise disrupts clinical workflows. This gap motivated an evaluation of how often these systems trigger. It was already known that alert overload contributes to staff burnout. That reality prompted a closer look at specific device behaviors. No prior work had resolved the distribution of these events in academic settings. This gap motivated a detailed review of two years of operational data.
Purpose Of The Study:
The aim of this investigation was to characterize the frequency and distribution of device alerts in a large academic hospital. This study sought to clarify how often these systems trigger during routine patient care. Researchers intended to identify which specific departments face the highest burden of alerts. The project examined data over a two-year period to ensure robust findings. This effort was motivated by the need to understand how alerts impact clinical environments. The team focused on mapping the variation of events across different care areas. By analyzing these patterns, the study provides insight into the prevalence of device-related interruptions. The work addresses the lack of detailed information regarding real-world alert performance in hospital settings.
Main Methods:
The review approach involved a retrospective examination of device logs over twenty-four months. Investigators gathered information from all inpatient wards within a major medical institution. The team utilized a specialized analytics platform to correlate infusion initiations with alert occurrences. Researchers organized the findings by department, alert classification, and numerical frequency. Statistical methods provided a summary of the gathered information. The design focused on quantifying the burden of alerts in real-world settings. This methodology ensured a comprehensive view of device behavior across different patient populations. The approach excluded non-inpatient areas to maintain consistency in the data set.
Main Results:
The researchers identified 5,129,505 total alerts linked to 1,102,303 infusion initiations. This equates to a mean of 4.65 alerts for every infusion started. Downstream occlusions accounted for 42.5% of all recorded events. Air-in-line alerts represented 15.5% of the total, while infusion-complete and upstream occlusions comprised 14.4% and 14.1% respectively. Neonatal intensive care units averaged 28.6 alerts per infusion. Pediatric units reported 9.0 alerts per infusion, and pediatric intensive care units averaged 7.7. Downstream occlusion rates peaked in pediatric units at 696 per 100 starts. Air-in-line alerts reached their maximum frequency in oncology at 103 per 100 starts.
Conclusions:
The authors suggest that downstream occlusions represent the most common category of device alerts. Researchers propose that pediatric and neonatal units experience a disproportionate burden of these events. The study indicates that high alarm rates per infusion increase the potential for staff fatigue. Authors observe that adult medical-surgical areas contribute the highest total volume of alerts. The researchers propose that targeted interventions could reduce the frequency of specific alarm types. The study highlights that air-in-line alerts remain a significant concern in oncology departments. Authors suggest that understanding care-area variation is necessary for improving patient safety protocols. The researchers propose that future efforts should focus on optimizing pump settings to mitigate these persistent challenges.
The researchers propose that downstream occlusions, air-in-line, infusion-complete, and upstream occlusion alerts account for 86.5% of all events. These four categories dominate the total volume of alerts recorded over the two-year period.
The study utilizes the Care Everywhere analytics platform to extract and aggregate event data. This tool allows for the systematic linking of infusion starts with specific alert triggers across various hospital departments.
The researchers propose that a large academic medical center is necessary to capture a sufficient volume of data for meaningful statistical analysis. This environment provides the diverse patient populations required to compare pediatric, neonatal, and adult care areas.
The study relies on retrospective data, which provides a longitudinal view of device performance. This approach allows for the comparison of 5,129,505 total alerts against 1,102,303 infusion starts over two years.
The researchers propose that the neonatal intensive care unit experiences 28.6 alerts per infusion. In contrast, pediatric units average 9.0, while pediatric intensive care units average 7.7 alerts per infusion.
The authors suggest that pediatric and neonatal areas face the greatest risk for alarm fatigue. This conclusion stems from the observation that these units experience the highest number of alerts per infusion despite lower total infusion volumes.