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Can a Log of Infusion Device Events Be Used to Understand Infusion Accidents?

Bitan, Yuval PhD; Nunnally, Mark E. MD

doi: 10.1097/pts.0b013e31815c482e
Original Articles

Objective: This study sought to determine whether infusion device event logs could support accident investigation.

Methods: An incident reporting database was searched for information about log file use in investigations. Log file data from devices in clinical use were downloaded and electronically searched for characteristics (signatures) matching specific function queries. Different programming sequences were simulated, and device logs were downloaded for analysis.

Results: Database reports mentioned difficulties resolving log file data to the incident report and used log file data to confirm programming failures. Log file search revealed that, aside from alarm types and times, the devices were unable to adequately satisfy functional queries. Different simulated programming scenarios could not be easily differentiated by log file analysis.

Conclusions: The device logs we studied collect data that are poorly suited to accident investigation. We conclude that infusion device logs cannot function as black boxes do in aviation accidents. Logs would be better applied to assist routine operations.

From the Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, Illinois.

Correspondence: Mark E. Nunnally, MD, Department of Anesthesia and Critical Care, University of Chicago Medical Center, 5841 South Maryland Ave, MC 4028, Chicago, IL 60637 (e-mail:

© 2007 Lippincott Williams & Wilkins, Inc.