Presentation
Human Factors in Intravenous Smart Pumps: Nurse–Pump Interactions and Workarounds to Manage Underdelivery During Antineoplastic Infusion Therapy
SessionPoster Session 1
DescriptionIntravenous smart pumps (IVSPs) are among the most used technologies in U.S. acute care settings, with more than 80% of hospitals relying on them for medication delivery. These devices are necessary in oncology treatment areas, where antineoplastic infusions are both high-risk and high workload. Holding the largest market share in the United States, large-volume linear peristaltic pumps (e.g., BD Alaris and Baxter), are prone to usability challenges and flow rate inaccuracies. Evidence continues to build that these devices contribute to medication underdelivery, requiring workarounds that can increase the risk of error in environments already strained by nursing shortages and high cognitive load.
Linear peristaltic pumps carry specific risks due to their design. Overfill of infusion containers, patient vascular access constraints, and imperfect setup conditions can directly and indirectly lead to incomplete medication delivery. Nurses often recognize or have learned to expect residual drug volumes in infusion containers at the “infusion completed” alert; because of this, end-users have adapted workflows to accommodate the limitations of the linear peristaltic pumps in the following ways: 1) overprogramming the “volume-to-be-infused” (VTBI) to ensure full drug delivery at initial programming, 2) programming additional VTBI at the initial end time, or 3) using the air-in-line alarm detection system to signal the end of infusion and thus adequate drug delivery. These workarounds are necessary to ensure full medication delivery, especially for costly, high-alert oncology drugs.
Purpose
This project examines common antineoplastic delivery scenarios while corroborating them with real-world IVSP data from the BD Alaris Infusion Knowledge Portal (IKP) to understand workarounds during cancer treatment. The objectives are to:
1. Characterize patterns of air-in-line alarms associated with select antineoplastic medications to signal end-of-infusion.
2. Use case studies of select long-duration antineoplastic infusions and supportive therapies to quantify the frequency of VTBI additions after initial programming.
3. Evaluate nurse–pump interaction patterns tied to mitigating medication underdelivery.
The authors of this analysis aim to share data and IVSP set-up configurations of infusion practices and workarounds in oncology-related infusion treatments. This information will help illuminate human–technology interactions that are currently invisible in published data.
Methods and Data Source
The project utilizes retrospective infusion pump data extracted from the BD Alaris IKP platform. The IKP is a web-based data repository that captures alarms, alerts, programming actions, and infusion status. For this project, data were analyzed through the lens of common clinical challenges reported by end users. Select small-volume medications, such as pembrolizumab and nivolumab, were examined to identify when air-in-line alarms occur near the expected end of infusion duration, highlighting the common workaround of overprogramming the VTBI so the air-in-line sensor triggers only after the fluid is depleted to this point. The analysis also describes how often VTBI adjustments are made at the end of long-duration antineoplastic infusions. Additionally, patterns of repeated adjustments were evaluated to characterize the frequency of nurse–pump interactions.
Application of Human Factors and Ergonomics (HFE) Principles
This project is grounded in core HFE principles:
• Usability and Interface Complexity: IVSPs require dozens of keystrokes to program, increasing error risk in high-interruption environments. Workarounds and repeated VTBI additions amplify this problem.
• Reliability and Safety: Flow rate deviations and underdelivery, confirmed in clinical reports, compromise the reliability of timely drug delivery.
• System-Level Risk: Repeated pump touches expose IV lines and increase the risk of infection while simultaneously increasing the chance of error during programming adjustments.
Integration with Literature
The literature demonstrates that underdelivery is both common and underrecognized. Hult et al. (2024) confirmed that linear peristaltic pumps can underdeliver programmed volumes due to infusion set elongation, without triggering alarms. Blake et al. (2025; 2025; 2025) note that linear peristaltic pumps remain based on 1990s-era mechanics and are especially prone to flow inaccuracies compared to cassette-based systems. Jennings et al. (2022) describe how interruptions, alarms, and equipment workarounds contribute to turbulent workflows that elevate cognitive burden and diminish nurse well-being. Together, these findings highlight the clinical reality: nurses must constantly detect, adapt, and compensate for IVSP shortcomings to protect patients.
Conclusions and Take-Home Message
IVSP usability and performance cannot be evaluated on laboratory accuracy alone. Real-world data corroborates end-user reports of workarounds and repeated nurse–pump interactions to mitigate underdelivery. These practices include the use of the air-in-line sensor as a surrogate “end-of-infusion” indicator, which compromises its primary safety function of detecting air. This seemingly benign practice introduces avoidable patient risk. Nurses are also frequently reprogramming additional VTBI to ensure full drug delivery, especially in long-duration infusions, which disrupts workflow efficiency.
By recognizing and quantifying VTBI adjustments along with end-of-infusion workarounds, this project showcases the need for a shift in IVSP design. Infusion devices must be informed by human factors engineering and shaped by the real-world experiences of frontline nurses. The findings highlight nurses’ essential role as expert end-users and reinforce the urgency for infusion technologies that align with the realities of modern oncology care.
References
Blake, J. W. C. (2025). Intravenous Pump Flow Accuracy: A Systematic Review. J Infus Nurs, 48(1), 44-52. https://doi.org/10.1097/NAN.0000000000000576
Blake, J. W. C., Butterfield, R., Hopper, T., & Sims, N. M. (2025). Secondary Infusion Underdelivery: Risks and Rewards of Common Workarounds. AACN Adv Crit Care, 36(3), 240-251. https://doi.org/10.4037/aacnacc2025893
Blake, J. W. C., Meade, K., & Giuliano, K. K. (2025). Intravenous Smart Pumps: A Review of the Safety Implications for the Most Ubiquitous Technology in US Acute Care. Critical Care Nursing Clinics of North America. https://doi.org/https://doi.org/10.1016/j.cnc.2025.01.004
Hult, A., Zholobova, I., Backlin, E., & Nydert, P. (2024). Flow Rate Deviation in Infusion Pump: Infusion Set Defect Enables Pump Malfunction and Considerable Accuracy Deviation. J Infus Nurs, 47(1), 30-35. https://doi.org/10.1097/NAN.0000000000000530
Jennings, B. M., Baernholdt, M., & Hopkinson, S. G. (2022). Exploring the turbulent nature of nurses’ workflow. Nursing Outlook, 70(3), 440-450. https://doi.org/https://doi.org/10.1016/j.outlook.2022.01.002
Linear peristaltic pumps carry specific risks due to their design. Overfill of infusion containers, patient vascular access constraints, and imperfect setup conditions can directly and indirectly lead to incomplete medication delivery. Nurses often recognize or have learned to expect residual drug volumes in infusion containers at the “infusion completed” alert; because of this, end-users have adapted workflows to accommodate the limitations of the linear peristaltic pumps in the following ways: 1) overprogramming the “volume-to-be-infused” (VTBI) to ensure full drug delivery at initial programming, 2) programming additional VTBI at the initial end time, or 3) using the air-in-line alarm detection system to signal the end of infusion and thus adequate drug delivery. These workarounds are necessary to ensure full medication delivery, especially for costly, high-alert oncology drugs.
Purpose
This project examines common antineoplastic delivery scenarios while corroborating them with real-world IVSP data from the BD Alaris Infusion Knowledge Portal (IKP) to understand workarounds during cancer treatment. The objectives are to:
1. Characterize patterns of air-in-line alarms associated with select antineoplastic medications to signal end-of-infusion.
2. Use case studies of select long-duration antineoplastic infusions and supportive therapies to quantify the frequency of VTBI additions after initial programming.
3. Evaluate nurse–pump interaction patterns tied to mitigating medication underdelivery.
The authors of this analysis aim to share data and IVSP set-up configurations of infusion practices and workarounds in oncology-related infusion treatments. This information will help illuminate human–technology interactions that are currently invisible in published data.
Methods and Data Source
The project utilizes retrospective infusion pump data extracted from the BD Alaris IKP platform. The IKP is a web-based data repository that captures alarms, alerts, programming actions, and infusion status. For this project, data were analyzed through the lens of common clinical challenges reported by end users. Select small-volume medications, such as pembrolizumab and nivolumab, were examined to identify when air-in-line alarms occur near the expected end of infusion duration, highlighting the common workaround of overprogramming the VTBI so the air-in-line sensor triggers only after the fluid is depleted to this point. The analysis also describes how often VTBI adjustments are made at the end of long-duration antineoplastic infusions. Additionally, patterns of repeated adjustments were evaluated to characterize the frequency of nurse–pump interactions.
Application of Human Factors and Ergonomics (HFE) Principles
This project is grounded in core HFE principles:
• Usability and Interface Complexity: IVSPs require dozens of keystrokes to program, increasing error risk in high-interruption environments. Workarounds and repeated VTBI additions amplify this problem.
• Reliability and Safety: Flow rate deviations and underdelivery, confirmed in clinical reports, compromise the reliability of timely drug delivery.
• System-Level Risk: Repeated pump touches expose IV lines and increase the risk of infection while simultaneously increasing the chance of error during programming adjustments.
Integration with Literature
The literature demonstrates that underdelivery is both common and underrecognized. Hult et al. (2024) confirmed that linear peristaltic pumps can underdeliver programmed volumes due to infusion set elongation, without triggering alarms. Blake et al. (2025; 2025; 2025) note that linear peristaltic pumps remain based on 1990s-era mechanics and are especially prone to flow inaccuracies compared to cassette-based systems. Jennings et al. (2022) describe how interruptions, alarms, and equipment workarounds contribute to turbulent workflows that elevate cognitive burden and diminish nurse well-being. Together, these findings highlight the clinical reality: nurses must constantly detect, adapt, and compensate for IVSP shortcomings to protect patients.
Conclusions and Take-Home Message
IVSP usability and performance cannot be evaluated on laboratory accuracy alone. Real-world data corroborates end-user reports of workarounds and repeated nurse–pump interactions to mitigate underdelivery. These practices include the use of the air-in-line sensor as a surrogate “end-of-infusion” indicator, which compromises its primary safety function of detecting air. This seemingly benign practice introduces avoidable patient risk. Nurses are also frequently reprogramming additional VTBI to ensure full drug delivery, especially in long-duration infusions, which disrupts workflow efficiency.
By recognizing and quantifying VTBI adjustments along with end-of-infusion workarounds, this project showcases the need for a shift in IVSP design. Infusion devices must be informed by human factors engineering and shaped by the real-world experiences of frontline nurses. The findings highlight nurses’ essential role as expert end-users and reinforce the urgency for infusion technologies that align with the realities of modern oncology care.
References
Blake, J. W. C. (2025). Intravenous Pump Flow Accuracy: A Systematic Review. J Infus Nurs, 48(1), 44-52. https://doi.org/10.1097/NAN.0000000000000576
Blake, J. W. C., Butterfield, R., Hopper, T., & Sims, N. M. (2025). Secondary Infusion Underdelivery: Risks and Rewards of Common Workarounds. AACN Adv Crit Care, 36(3), 240-251. https://doi.org/10.4037/aacnacc2025893
Blake, J. W. C., Meade, K., & Giuliano, K. K. (2025). Intravenous Smart Pumps: A Review of the Safety Implications for the Most Ubiquitous Technology in US Acute Care. Critical Care Nursing Clinics of North America. https://doi.org/https://doi.org/10.1016/j.cnc.2025.01.004
Hult, A., Zholobova, I., Backlin, E., & Nydert, P. (2024). Flow Rate Deviation in Infusion Pump: Infusion Set Defect Enables Pump Malfunction and Considerable Accuracy Deviation. J Infus Nurs, 47(1), 30-35. https://doi.org/10.1097/NAN.0000000000000530
Jennings, B. M., Baernholdt, M., & Hopkinson, S. G. (2022). Exploring the turbulent nature of nurses’ workflow. Nursing Outlook, 70(3), 440-450. https://doi.org/https://doi.org/10.1016/j.outlook.2022.01.002
Event Type
Poster Presentation
TimeMonday, March 234:45pm - 6:15pm EDT
LocationRhinelander Gallery
Medical and Drug Delivery Devices