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Introduction: Infusion pumps are important clinical tools where controlled and precise infusions are needed. However, there are a number of potential risks for patient safety in their use: There is a risk of free-flow, i.e. an uncontrolled infusion that may have fatal consequences to the patient; staff is often poorly trained to use these devices, and often the devices themselves do not offer much support in this regard., Material and Methods: Technical and organisational data regarding the use of infusion pumps in the hospitals of the Copenhagen Hospital Corporation (CHC) were collected and analysed. Critical incidents reported to the CHC Incident Database were analysed., Results: Forty-two different infusion pumps are in use by the five CHC hospitals. There was a total of 919 volumetric infusion pumps, 71% having set-based free-flow protection. Critical incidents were in 40% of cases caused by user-error, the most common being setting an incorrect infusion rate. Discontinuation of the infusion was reported in 27% of incident reports, the causes being disconnection or kinking of the infusion line; this resulted in two cases of awareness under anaesthesia., Conclusion: Centralising the decision process for procurement and establishing a central library of standardised equipment might well reduce patient safety risks and any under-use of equipment. Usability testing prior to procurement decisions is vital; such testing should be performed by validated methods and not simply by putting the pumps to test in a clinical setting. More knowledge about user-friendly designs of medical equipment is needed.

Introduction: This article describes the methods and results of a project in the Copenhagen Hospital Corporation (H:S) on preventing adverse events. The aim of the project was to raise awareness about patients' safety, test a reporting system for adverse events, develop and test methods of analysis of events and propagate ideas about how to prevent adverse events., Materials and Methods: H:S developed an action plan and a reporting system for adverse events, founded an organization and developed an educational program on theories and methods of learning from adverse events for both leaders and employees., Results: During the three-year period from 1 January 2002 to 31 December 2004, the H:S staff reported 6011 adverse events. In the same period, the organization completed 92 root cause analyses. More than half of these dealt with events that had been optional to report, the other half events that had been mandatory to report., Conclusion: The number of reports and the front-line staff's attitude towards reporting shows that the H:S succeeded in founding a safety culture. Future work should be centred on developing and testing methods that will prevent adverse events from happening. The objective is to suggest and complete preventive initiatives which will help increase patient safety.