Hi everyone,
Our hospitals recently switched to BBraun large volume pumps from an ancient Baxter fleet. As those who use them know, to program a rate you click left for each place value and then up or down to reach the desired value. So for 20, you would click left twice and up twice to get 2-0.

We recently had an error in which a patient was receiving norepinephrine 18mcg/min. When the RN was attempting to change the rate, she clicked too many times to the left, prompting a change in the hundreds place. The resulting rate (>100mcg/min) exceeded the hard max limit. The pump alerted the nurse with the upper soft limit and prompted her to "Override with 100mcg/min" (the hard max). She selected Yes and the infusion was started. The patient received several minutes of this ~5x overdose. Their vitals clearly reflected the overdose so thankfully the error was detected quickly and appropriate measures were taken to stabilize the patient.

We were concerned about the use of the place value programming when we went live and tried to take it into consideration when programming limits. However, I'm not sure we were aware that exceeding a hard limit prompts to go to the hard limit, rather than to require reprogramming. When I look at the screen (attached), I can see how easily it would be to press Yes to just keep moving forward because you don't realize you made an error in the first place. We are contacting BBraun to find out if this is a setting that can be adjusted.

I am gathering more details and will report to ISMP when complete. Does anyone else have experience with this issue and have any pearls to share? I'm curious if BBraun has heard similar concerns before and other than independent double checks, other system changes you identified to reduce the risk of error? We discussed a hard max review but the core issue here is really the pump encouraging an overdose following a data entry error.

Thanks in advance for any insights!
Erin