Intravenous (IV) infusion pumps are commonly used in healthcare settings to deliver medications, fluids, and nutrients to patients at controlled rates. Approximately 90 percent of hospitalized patients receive an IV infusion as part of their medical treatment (Husch et al., 2005). The use of computerized smart pump technology in hospitals has increased from approximately 33% in 2005 to almost 50% in 2009 (Brady, 2010). In recent years, smart infusion pumps have gradually become more sophisticated and include safety features such as dose error reduction software, drug libraries, and the ability for healthcare facilities to set limitations on preselected drugs (Cummings & McGowan, 2011). This technology allows healthcare providers to program,…show more content… In order to encourage the use of safeguards, I needed to do more research on medication infusion pumps, what can go wrong with infusion pumps, and the implications for nurse leaders in addressing medication errors when smart infusion pumps are used. In my research I learned that IV infusions are associated with 54% of potential adverse drug events, 56% of medication errors, and 61% of serious and life-threatening errors (Santell, 2008). The United States Food and Drug Administration (FDA) has initiated a program aimed at preventing infusion problems and improving patient safety after receiving 56,000 reports of infusion pump incidents, including 710 deaths, between 2005 and 2009 (Brady, 2010). The most common sources of errors include programming incorrect drug doses, overriding pump limitations, failing to use preprogrammed libraries, and failing to perform the five rights of medication administration. Precautions that can be taken to prevent errors include ensuring infusion pump is programmed correctly, confirming pump settings with a second clinician when infusing high risk medications, using drug libraries according to facility policy, labeling infusion pump channels when multiple lines are infusing at one time, monitoring patient and infusion (do not rely on pump to do the monitoring), paying attention to infusion pump alerts and cautions, and continuously monitoring…show more content… During this time, I had the opportunity to spend time with the nurse educator and learn more about his role in the facility. For this particular event, my role was to interview the nurses and find out why infusion pump safeguards were being overridden, what medications were not programmed in the drug library, and what some situations were where they had to infuse medications in basic mode (which is against facility policy). It was interesting to listen to the nurses’ responses and learn their perspective of the problem. It was also interesting to hear what they would like administration to do about the problem. Taking back the information I gathered and sharing their perspectives with the nurse leaders was also interesting and a good learning experience. This experience increased my knowledge of the CNS role in administration, collaboration, and clinical practice. The experience definitely made me see what a vital role CNS’ play in making changes on clinical policies and guidelines to be followed by bedside nurses and how acknowledging the RNs concerns can ultimately lead to better outcomes for