Can a log of infusion device events be used to understand infusion accidents?

Yuval Bitan, Mark E. Nunnally

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


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.

Original languageEnglish
Pages (from-to)208-213
Number of pages6
JournalJournal of Patient Safety
Issue number4
StatePublished - 1 Dec 2007
Externally publishedYes


  • Accident investigation
  • Data recording
  • Incident reporting
  • Infusion devices
  • Patient safety

ASJC Scopus subject areas

  • Leadership and Management
  • Public Health, Environmental and Occupational Health


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