An IV pump malfunction caused a patient to receive only half the prescribed medication dose for over 7 hours, and the issue was not caught because the pump's volume-to-be-infused (VTBI) reading was inaccurate, leading to delayed patient stabilization.

Workarounds Described

• manually draining the bag and line to measure remaining volume
• adding extra volume to infused amount to compensate for alarm
• relying on double-sign-off at shift change to catch inconsistencies
• switching out the pump entirely as a diagnostic step

Implied Software Gaps

• Real-time volumetric infusion monitoring that cross-references programmed dose vs delivered volume and alerts on discrepancy
• Independent sensor-based verification of pump performance without relying on pump's internal VTBI reading
• Integration of pump data with patient electronic medical record to flag potential under-infusion trends over time

InfusionGuard Pro

InfusionGuard Pro is a smart IV infusion monitor that attaches to existing pumps to independently track volume delivered using a non-invasive flow sensor. It cross-checks against pump settings and alerts in real-time when actual delivery diverges from prescribed dose, preventing silent under-infusion. Unlike relying solely on pump internal sensors, it provides an independent verification layer.

Existing Solutions Mentioned