Presentation
Human Factors in Infusion Safety: Usability, Accuracy, and Alarm Burden of Intravenous Smart Pumps
DescriptionSubmission Summary
Large volume intravenous smart pumps (IVSPs) are widely considered essential technologies for the safe delivery of medications in acute and critical care settings. They are designed to deliver lifesaving drugs with precision, provide decision-support through dose error reduction software, and safeguard against medication errors. Although widely adopted, infusion pumps continue to present concerns with usability, flow rate accuracy, and clinically insignificant alarms. As the primary users of IVSPs, nurses regularly encounter non-intuitive interfaces, programming complexity, and frequent nuisance alarms that interrupt workflow and erode trust in the technology. These challenges not only increase cognitive workload and risk of error but also have a direct impact on patient safety and clinical efficiency.
This session will provide a comprehensive review of IVSP usability and performance, supported by real-world data (RWD) derived from clinical observations, simulation studies, and clinical studies on usability, alarms/alarm fatigue, and flow rate accuracy. The content is directly aligned with human factors and ergonomics principles, highlighting how device design and interface complexity intersect with nursing workflow, decision-making, and patient outcomes.
The Institute of Medicine’s landmark report To Err Is Human (1999) emphasized the importance of designing safer systems to reduce preventable harm. IVSP medication administration in acute care is one of the highest-risk processes in healthcare. Unfortunately, IV infusion remains a leading source of adverse events, and IVSP-related issues are regularly reported to the FDA and ECRI as major patient safety concerns. In today’s environment of persistent nursing shortages, the demand on clinicians is greater than ever, making it critical that device user interfaces be designed with human factors principles in mind. Usability, workflow alignment, and cognitive load reduction are no longer optional features but essential requirements to support safe and efficient care delivery.
Research from our interdisciplinary nurse–engineer program has consistently demonstrated that poor IVSP usability and alarm burden significantly impact the delivery of care for nurses and the experience of care for patients.
• Usability Challenges: Non-intuitive interfaces prolong programming time, increase mental workload, and elevate the likelihood of programming errors.
• Flow Rate Accuracy: Variability reduces reliability in critical infusions and can delay the timely completion of medications delivered through IV smart pump technology, posing risks to patient safety.
• Alarm Burden: Frequent alarms that lack clinical relevance interrupt workflow, pause medication delivery, contribute to nurse alarm fatigue, disturb patient sleep, and increase infection risk due to unnecessary line handling.
Application to Practice and Human Factors
The session will provide an overview of the interdisciplinary research we have conducted, share the findings and our plans for future research in the very important area of patient safety. We will also our work in translating research findings into practice-oriented takeaways for clinicians, pharmacists, clinical engineers, human factors specialists, and manufacturers of IV smart pumps.
Demonstrate how real-world usability challenges and the impact on patient care.
• Show the direct connection between interface design, programming steps, and clinical decision-making.
• Highlight the consequences of alarm fatigue, both for nurse well-being and patient safety.
• Provide evidence-based strategies that nurses and healthcare leaders can apply now to improve safety, efficiency, and system trust.
Human factors professionals attending this session will gain insight into the critical role of nursing and clinical workflow in infusion safety, and how iterative, nurse-centered design processes can improve both technology usability, clinical outcomes, and be used to inform future IVSP innovation.
Overview of the Presentation
The presentation will be highly interactive and organized in the following way:
1. Introduction
o Brief overview of IVSPs as essential technologies for medication safety.
o Current challenges related to usability, flow accuracy, and alarm burden.
o Framing the importance of human factors in understanding mitigating risks.
2. Real-World Data (RWD) Findings
o Simulation studies: NASA-TLX and eye-tracking data illustrating cognitive workload and error risk.
o Clinical observations: Nursing workflow disruptions linked to poor interface design.
o Alarm log analysis: Frequency, type, and impact of clinically insignificant alarms across multiple hospitals and different IVSP systems.
o Real-world case studies to clearly demonstrate impact on nurses and patients.
3. Hands-On Demonstrations
o Live interface walk-throughs showing how programming complexity contributes to errors.
o Demonstrations of common alarm scenarios that highlight workflow interruptions.
o Interactive discussion with attendees on potential redesign strategies.
o Real-world case studies to clearly demonstrate impact on nurses and patients.
4. Regulatory and Professional Landscape
o Multiple recalls and safety communications highlight IVSP issues (software errors, flow rate inaccuracies, alarm malfunctions).
o Numerous professional organizations, including ISMP and AAMI, emphasize alarm fatigue, usability, and interface design as persistent risks.
o Current testing for regulatory clearance is limited to assess real-world performance
5. Practical Strategies and Future Directions
o Evidence-based recommendations for improving infusion safety now
o Guidance for hospitals on making informed purchasing decisions, emphasizing the importance of including frontline nurses as stakeholders.
o A vision for the future of IVSP design grounded in nurse-led innovation, interdisciplinary collaboration, and human-centered design principles.
6. Key takeaways for attendees include:
o Real-world impact: Device design directly affects clinical efficiency, decision-making, and patient safety.
o Actionable strategies: Nurses and healthcare leaders can implement evidence-based practices now to mitigate risks.
o Hands-on insight: Demonstrations will allow participants to see and feel how usability challenges impact real-world clinical use.
o Future innovation: The next generation of IVSPs must be shaped by nurse-led end-user input, human factors science, and interdisciplinary innovation.
7. Alignment with HFES
• Applying human factors principles to healthcare technology design and use.
• Demonstrating the impact of design on cognitive workload and error risk.
• Bridging research, practice, and industry perspectives.
• Highlighting how ergonomics can inform both immediate safety improvements and long-term product innovation.
Large volume intravenous smart pumps (IVSPs) are widely considered essential technologies for the safe delivery of medications in acute and critical care settings. They are designed to deliver lifesaving drugs with precision, provide decision-support through dose error reduction software, and safeguard against medication errors. Although widely adopted, infusion pumps continue to present concerns with usability, flow rate accuracy, and clinically insignificant alarms. As the primary users of IVSPs, nurses regularly encounter non-intuitive interfaces, programming complexity, and frequent nuisance alarms that interrupt workflow and erode trust in the technology. These challenges not only increase cognitive workload and risk of error but also have a direct impact on patient safety and clinical efficiency.
This session will provide a comprehensive review of IVSP usability and performance, supported by real-world data (RWD) derived from clinical observations, simulation studies, and clinical studies on usability, alarms/alarm fatigue, and flow rate accuracy. The content is directly aligned with human factors and ergonomics principles, highlighting how device design and interface complexity intersect with nursing workflow, decision-making, and patient outcomes.
The Institute of Medicine’s landmark report To Err Is Human (1999) emphasized the importance of designing safer systems to reduce preventable harm. IVSP medication administration in acute care is one of the highest-risk processes in healthcare. Unfortunately, IV infusion remains a leading source of adverse events, and IVSP-related issues are regularly reported to the FDA and ECRI as major patient safety concerns. In today’s environment of persistent nursing shortages, the demand on clinicians is greater than ever, making it critical that device user interfaces be designed with human factors principles in mind. Usability, workflow alignment, and cognitive load reduction are no longer optional features but essential requirements to support safe and efficient care delivery.
Research from our interdisciplinary nurse–engineer program has consistently demonstrated that poor IVSP usability and alarm burden significantly impact the delivery of care for nurses and the experience of care for patients.
• Usability Challenges: Non-intuitive interfaces prolong programming time, increase mental workload, and elevate the likelihood of programming errors.
• Flow Rate Accuracy: Variability reduces reliability in critical infusions and can delay the timely completion of medications delivered through IV smart pump technology, posing risks to patient safety.
• Alarm Burden: Frequent alarms that lack clinical relevance interrupt workflow, pause medication delivery, contribute to nurse alarm fatigue, disturb patient sleep, and increase infection risk due to unnecessary line handling.
Application to Practice and Human Factors
The session will provide an overview of the interdisciplinary research we have conducted, share the findings and our plans for future research in the very important area of patient safety. We will also our work in translating research findings into practice-oriented takeaways for clinicians, pharmacists, clinical engineers, human factors specialists, and manufacturers of IV smart pumps.
Demonstrate how real-world usability challenges and the impact on patient care.
• Show the direct connection between interface design, programming steps, and clinical decision-making.
• Highlight the consequences of alarm fatigue, both for nurse well-being and patient safety.
• Provide evidence-based strategies that nurses and healthcare leaders can apply now to improve safety, efficiency, and system trust.
Human factors professionals attending this session will gain insight into the critical role of nursing and clinical workflow in infusion safety, and how iterative, nurse-centered design processes can improve both technology usability, clinical outcomes, and be used to inform future IVSP innovation.
Overview of the Presentation
The presentation will be highly interactive and organized in the following way:
1. Introduction
o Brief overview of IVSPs as essential technologies for medication safety.
o Current challenges related to usability, flow accuracy, and alarm burden.
o Framing the importance of human factors in understanding mitigating risks.
2. Real-World Data (RWD) Findings
o Simulation studies: NASA-TLX and eye-tracking data illustrating cognitive workload and error risk.
o Clinical observations: Nursing workflow disruptions linked to poor interface design.
o Alarm log analysis: Frequency, type, and impact of clinically insignificant alarms across multiple hospitals and different IVSP systems.
o Real-world case studies to clearly demonstrate impact on nurses and patients.
3. Hands-On Demonstrations
o Live interface walk-throughs showing how programming complexity contributes to errors.
o Demonstrations of common alarm scenarios that highlight workflow interruptions.
o Interactive discussion with attendees on potential redesign strategies.
o Real-world case studies to clearly demonstrate impact on nurses and patients.
4. Regulatory and Professional Landscape
o Multiple recalls and safety communications highlight IVSP issues (software errors, flow rate inaccuracies, alarm malfunctions).
o Numerous professional organizations, including ISMP and AAMI, emphasize alarm fatigue, usability, and interface design as persistent risks.
o Current testing for regulatory clearance is limited to assess real-world performance
5. Practical Strategies and Future Directions
o Evidence-based recommendations for improving infusion safety now
o Guidance for hospitals on making informed purchasing decisions, emphasizing the importance of including frontline nurses as stakeholders.
o A vision for the future of IVSP design grounded in nurse-led innovation, interdisciplinary collaboration, and human-centered design principles.
6. Key takeaways for attendees include:
o Real-world impact: Device design directly affects clinical efficiency, decision-making, and patient safety.
o Actionable strategies: Nurses and healthcare leaders can implement evidence-based practices now to mitigate risks.
o Hands-on insight: Demonstrations will allow participants to see and feel how usability challenges impact real-world clinical use.
o Future innovation: The next generation of IVSPs must be shaped by nurse-led end-user input, human factors science, and interdisciplinary innovation.
7. Alignment with HFES
• Applying human factors principles to healthcare technology design and use.
• Demonstrating the impact of design on cognitive workload and error risk.
• Bridging research, practice, and industry perspectives.
• Highlighting how ergonomics can inform both immediate safety improvements and long-term product innovation.
Event Type
Oral Presentations
TimeTuesday, March 242:37pm - 3:00pm EDT
LocationGramercy