Attributes of errors, facilitators, and barriers related to rate control of IV medications: a scoping review

Background Intravenous (IV) medication is commonly administered and closely associated with patient safety. Although nurses dedicate considerable time and effort to rate the control of IV medications, many medication errors have been linked to the wrong rate of IV medication. Further, there is a lack of comprehensive studies examining the literature on rate control of IV medications. This study aimed to identify the attributes of errors, facilitators, and barriers related to rate control of IV medications by summarizing and synthesizing the existing literature. Methods This scoping review was conducted using the framework proposed by Arksey and O’Malley and PRISMA-ScR. Overall, four databases—PubMed, Web of Science, EMBASE, and CINAHL—were employed to search for studies published in English before January 2023. We also manually searched reference lists, related journals, and Google Scholar. Results A total of 1211 studies were retrieved from the database searches and 23 studies were identified from manual searches, after which 22 studies were selected for the analysis. Among the nine project or experiment studies, two interventions were effective in decreasing errors related to rate control of IV medications. One of them was prospective, continuous incident reporting followed by prevention strategies, and the other encompassed six interventions to mitigate interruptions in medication verification and administration. Facilitators and barriers related to rate control of IV medications were classified as human, design, and system-related contributing factors. The sub-categories of human factors were classified as knowledge deficit, performance deficit, and incorrect dosage or infusion rate. The sub-category of design factor was device. The system-related contributing factors were classified as frequent interruptions and distractions, training, assignment or placement of healthcare providers (HCPs) or inexperienced personnel, policies and procedures, and communication systems between HCPs. Conclusions Further research is needed to develop effective interventions to improve IV rate control. Considering the rapid growth of technology in medical settings, interventions and policy changes regarding education and the work environment are necessary. Additionally, each key group such as HCPs, healthcare administrators, and engineers specializing in IV medication infusion devices should perform its role and cooperate for appropriate IV rate control within a structured system. Supplementary Information The online version contains supplementary material available at 10.1186/s13643-023-02386-z.


Background
Medication errors are closely associated with patient safety and the quality of care [1,2].In particular, medication errors, which denote a clinical issue of global importance for patient safety, negatively affect patient morbidity and mortality and lead to delays in discharge [3,4].The National Health Service in the UK estimates that 237 million medication errors occur each year, of which 66 million cause clinically significant harm [5].The US Food and Drug Administration reported that they received more than 100,000 reports each year associated with suspected medication errors [6].Additionally, it was estimated that 40,000-98,000 deaths per year in the USA could be attributed to errors by healthcare providers (HCPs) [7].Previous studies have revealed that medication errors account for 6-12% of hospital admissions [8].
Intravenous (IV) medication is a common treatment in hospitalized patient care [9].It is used in wards, intensive care units (ICUs), emergency rooms, and outpatient clinics in hospitals [9,10].As direct HCPs, nurses are integral in patient safety during the IV medication process which could result in unintended errors or violations of recommendations [3].As many drugs injected via the IV route include high-risk drugs, such as chemotherapy agents, insulin, and opioids [10], inappropriate dose administration could lead to adverse events (AEs), such as death and life-threatening events [11,12].
IV medication process is a complex and multistage process.There are 12 stages in the IV medication process, which can be classified as follows: (1) obtain the drug for administration, (2) obtain the diluent, (3) reconstitute the drug in the diluent, (4) take the drug at the patient's bedside, (5) check for the patient's allergies, (6) check the route of drug administration, (7) check the drug dose, (8) check the patency of the cannula, (9) expel the air from the syringe, (10) administer the drug, (11) flush the cannula, and (12) sign the prescription chart [13].IV medication errors can occur at any of these stages.It is imperative to administer the drug at the correct time and rate during the IV medication process [13].The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defined an error in IV medication rates as "too fast or too slow rate than that intended" [14].Maintaining the correct rate of IV medication is essential for enhancing the effectiveness of IV therapy and reducing AEs [9].
Infusion pumps are devices designed to improve the accuracy of IV infusions, with drug flow, volume, and timing programmed by HCPs [15].A smart pump is an infusion pump with a software package containing a drug library.During programming, the smart pump software warns users about entering drug parameters that deviate from the recommended parameters, such as the type, dose, and dosage unit of the drug [15].In the absence of a device for administering IV medication, such as an infusion pump or smart pump, the IV rate is usually controlled by counting the number of fluid drops falling into the drip chamber [9].
According to the previous study, applying an incorrect rate was the most prevalent IV medication error, accounting for 536 of 925 (57.9%) total IV medication errors [16].Although rate control of IV medications is critical to patient safety and quality care, few studies review and map the relevant literature on rate control of IV medications.Therefore, this study aimed to identify the attributes of errors, facilitators, and barriers related to rate control of IV medications by summarizing the existing literature.
The specific research questions of this study are as follows: 1) What are the general characteristics of the studies related to rate control of IV medications?2) What are the attributes of errors associated with rate control of IV medications?3) What are the facilitators and barriers to rate control of IV medications?

Methods
This scoping review followed the framework suggested by Arksey and O'Malley [17] and developed by Levac et al. [18] and Peters et al. [19].Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) developed in 2020 by the Joanna Briggs Institute (JBI) were used to ensure reliability in the reporting of methodology (Additional file 1) [19].

Search strategy
According to the JBI Manuals for Evidence Synthesis, a three-step search strategy was adopted [19].First, a preliminary search in PubMed was conducted based on the title, abstract, keywords, and index terms of articles to develop our search strategy.In the preliminary search, we used keywords such as "patients, " "nurse, " "IV therapy, " "monitoring, " "rate, " and "medication error." The search results indicated that studies on medical devices and system-related factors were excluded.Therefore, we decided to exclude the keywords "patients" and "nurse" and focus on "IV therapy, " "monitoring, " "rate, " and "medication error" to comprehensively include studies on factors associated with rate control of infusion medications.Secondly, we used all identified keywords and index terms across all included databases following consultations with a research librarian at Yonsei University Medical Library to elaborate our search strategy.
Four databases-PubMed, CINAHL, EMBASE, and Web of Science-were searched using the keywords, index terms, and a comprehensive list of keyword variations to identify relevant studies published before January 2023.The details of the search strategy are described in Additional file 2. All database search results were exported into Endnote version 20.Finally, we manually searched the reference lists of the included articles identified from the database search.Furthermore, we manually searched two journals related to medication errors and patient safety, and Google Scholar to comprehensively identify the relevant literature.When performing a search on Google Scholar, keywords such as "medication, " "rate, " "IV therapy, " "intravenous administration, " and "medication error" were appropriately combined using search modifiers.

Eligibility criteria
Inclusion criteria were established according to the participants, concept, and context (PCC) framework recommended by the JBI manuals for scoping reviews [19].
The participants include patients receiving IV therapy, HCPs involved in administering IV medications, and experts from non-healthcare fields related to rate control of IV medications.The concepts were facilitators and barriers to rate control of IV medications, and the contexts were the environments or situations in which errors in rate control of IV medications occurred.While screening the literature identified by the three-step search based on the inclusion criteria, we refined the exclusion criteria through discussion among researchers.The exclusion criteria were as follows: (1) not available in English, (2) not an original article, (3) studies of medication errors in general, (4) not accessible, or (5) prescription error.

Study selection
Once duplicates were automatically removed through Endnote, two independent researchers assessed the eligibility of all articles by screening the titles and abstracts based on the inclusion and exclusion criteria.Studies identified via database searches were screened by GWR and YK and studies identified via other methods were screened by SBY and YK.Full-text articles were obtained either when the studies met the inclusion criteria or when more information was needed to assess eligibility and the researchers independently reviewed the full-text articles.In case of any disagreement in the study selection process, a consensus was reached through discussion among three researchers (GWR, SBY, and YK) and a senior researcher (JP).

Data extraction
Through consensus among the researchers, a form for data extraction was developed to extract appropriate information following the JBI manuals for scoping reviews [19].The following data were collected from each study: author information, publication year, country, study design, study period, aims, participants or events (defined as the occurrences related to patient care focused on in the study), contexts, methods, errors related to the control of IV medications (observed results or intervention outcomes), error severity, facilitators, and barriers according to the NCC MERP criteria.Three researchers (GWR SBY, and YK) independently conducted data charting and completed the data extraction form through discussion.

Data synthesis
The general characteristics of included studies such as publication year, country, study design, and study period were analyzed using descriptive statistics to identify trends or patterns.The aims, participants, events, contexts, and methods of the included studies were classified into several categories through a research meeting including a senior researcher (JP) to summarize and analyze the characteristics of the included studies comprehensively.Attributes of errors associated with rate control of IV medications were analyzed and organized through consensus among researchers based on extracted data.Facilitators and barriers to rate control of IV medications were independently classified according to NCC MERP criteria by three researchers (GWR, SBY, and YK) and iteratively modified.Discrepancies were resolved by discussion and re-reading the articles, with the final decision made in consultation with the senior researcher (JP).

Study selection
A total of 1211 studies were selected through a database search.After reviewing the titles and abstracts of the studies, 42 studies were considered for a detailed assessment by the three researchers.In particular, 2 were not available in English, 3 were not original articles, 24 were studies of medication error in general without details on rate control of IV medications, 2 were regarding prescription errors, and 1 was not accessible.Finally, 10 studies were identified through a database search.Additionally, 23 studies were identified from a manual search.Among the 23, 5 were not original articles, and 6 were studies on medication error in general.Finally, 12 studies were identified via other methods.Hence, 22 studies were included in the data analysis (Fig. 1, Additional file 3).

Participants and events
Participants in the 22 studies included HCPs such as nurses, doctors, pharmacists, and patients.Notably, four of these studies were only for nurses [31,37,38,40] and there was also one study involving only pharmacists [36].Furthermore, there were five studies wherein people from various departments or roles participated [23,[26][27][28]39].There were three studies wherein the patients were participants, and two studies included both patients and medical staff [29,33].Among the included studies, nine studies focused on errors in IV medication preparation and administration as events [23, 26, 30, 32-34, 37, 38, 40] and five studies focused on the administration process only [30,32,34,37,40].Four studies focused on problems in the administration of all types of drugs including errors associated with rate control of IV medications [2,22,28,29].Additionally, four studies focused on events that occurred with IV medication infusion devices [24,27,35,39], two studies explored the events that occurred during chemotherapy [22,25], and some analyzed events with problems in vascular access [21], iatrogenic events among neonates [28], and critical events in anesthesia cases [20].

Contexts and methods
The contexts can be largely divided into healthcare settings, including hospitals and laboratory settings.Three hospital-based studies were conducted in the entire hospital [20,22,24], eight studies were conducted at several hospitals, and the number of hospitals involved varied from 2 to 132 [23, 26, 32-35, 38, 40].Furthermore, four studies were conducted in different departments within one hospital [29,30,37,39], three studies were conducted in only one department [2,27,28], two studies considered other healthcare settings and were not limited to hospitals [21,25], and one study was conducted in a simulation laboratory setting that enabled a realistic simulation of an ambulatory chemotherapy unit [31].
Specifically, seven out of the nine studies developed or implemented interventions based on interdisciplinary or multidisciplinary collaboration [22,24,28,30,34,37,39].Two studies developed and identified the effectiveness of interventions that created an environment for nurses to improve performance and correct errors associated with medication administration [31,39], and two intervention studies were on error reporting methods or observation tools and the processes of addressing reported errors [28,30].There were also a study on a pharmacist-led educational program for nurses [37], a comprehensive intervention from drug prescription to administration to reduce chemotherapy-related medication errors [22], infusion safety intervention bundles [34], the implementation of a smart IV pump equipped with failure mode and effects analysis (FMEA) [24], and a smart system to prevent pump programming errors [27].

Attributes of errors associated with rate control of IV medications
Table 2 presents the attributes of errors related to rate control of IV medications in observed results or intervention outcomes, and error severity.Notably, 6 of 13 studies presenting observed results reported errors related to IV medication infusion devices among the rate control errors [20,25,32,33,35,36].Additionally, four studies reported errors in bolus dose administration or IV push and flushing lines among IV rate errors [2,23,36,40].Among the 13, nine studies reported error severity, and among these, three studies used NCC MERP ratings [25,32,33].In four studies, error severity was reported by describing several cases in detail [2,21,23,25], and two studies reported no injuries or damages due to errors [26,29].Among the nine studies that developed interventions and identified their effectiveness, four presented the frequency of incorrect rate errors as an outcome variable [28,30,34,37].Moreover, two studies suggested compliance rates for intervention as outcome variables [24,31].
Among the nine project or experiment studies, three showed a decrease in error rate as a result of the intervention [28,31,34].Three studies developed interventions to reduce rate errors but did not report the frequency or incidence of rate errors [22,24,27].A study reported the frequency of rate errors only after the intervention; the effect of the intervention could not be identified [30].Also, three studies showed the severity of errors related to rate control of IV medications [24,30,34], two used NCC MERP severity ratings [30,34], and one reported that all errors caused by smart IV pumps equipped with FMEA resulted in either temporary harm or no harm [24].

Facilitators and barriers to rate control of IV medications
Table 3 presents the facilitators and barriers related to rate control of IV medications according to the NCC MERP taxonomy based on the 22 included studies.Subcategories of human factors were classified as knowledge deficit, performance deficit, miscalculation of dosage or infusion rate, and stress.The sub-category of design factor was device.System-related contributing factors were classified as frequent interruptions and distractions, inadequate training, poor assignment or placement of HCPs or inexperienced personnel, policies and procedures, and communication systems between HCPs [14].

Human factors
Among the barriers extracted from the 22 studies, 11 factors belonged to the "knowledge deficit, " "performance

First author (year) Observed results or intervention outcomes
Error severity Short (1993) [20] ▪ Anesthetic critical events due to syringe pump failure (n = 2, 1.6%) NA Singleton (1993) [21] ▪ Incidents with vascular system access related to the administration of drugs at an unintended rate (n = 2, 3%) -Prompt collapse of the veins -Rapid onset of anesthesia -Retrograde flow of blood from the patient Goldspiel (2000) [22] ▪ Among the 23 modifications suggested by the task force, 2 modifications were related to the infusion pump; standardize portable pumps used throughout hospital, develop policy and procedure for standardizing overfill for infusion pump preparations NA Taxis (2003) [23] ▪ Giving bolus doses too quickly (n = 168, 63.4%) -Additional midazolam and bolus dose of adrenaline administration due to delay of continuous adrenaline infusion

Wetterneck (2006) [24]
▪ There were 18 problems after implementing the smart IV pump ▪ Two weeks after implementation, a 475-infusion audit found the drug library was used in 99.6% of medication infusions, channel labels in 80%, and the correct profile in 97% ▪ Six weeks later, in a 485-infusion audit, 99.6% of medication infusions used the drug library, 76% used channel labels, and 96% had the correct profile ▪ Approximately, 3 dosing alerts per day resulted in reprogrammed doses, which prevented potential pump programming errors from reaching patients Temporary harm or no harm Rinke (2007) [25] ▪ Errors in equipment and medication delivery devices (n = 68 of 547 possible error causes, 12.4%) ▪ Two medications were hung at the same time for the same patient, and their infusion rates were reversed (n = 1 of 310 error reports, 0.3%) NCC MERP severity ratings: E (the case of reversed infusion rates) Nuckols (2008)

Categories by NCC MERP a Sub-categories Facilitators Barriers
Human factors Knowledge deficit -Lack of knowledge about vascular access related to patient posture [20] -Lack of knowledge about medication equipment [23] -Lack of drug knowledge about medications [24] Performance deficit -Failure to check equipment properly [21] -Tubing misplacement [24,35] -Monitoring inadequate [25] -Non-compliance with protocols and guidelines [2,25] -Human handling errors with smart pumps [30] Miscalculation of dosage or infusion rate -Error in infusion speed calculation [29] Stress (high-volume workload) -High workload and distractions [23] -Error-prone ICU environment due to the heavy workload and complex critical care [37] Design Devices -Expanding smart IV pump capabilities [26] -Monitoring pump programming at the system level [27] -Standardization of infusion pumps [22] -Using patient-controlled analgesia pumps and syringe drivers [28] -Unexpected equipment faults [2,20,25,35,38] -Misassembly of an unfamiliar infusion pump [21] -Complex design of the equipment [23,24] -Smart pumps that were not connected to electronic systems [30] -Incomplete drug libraries in smart pumps [33] Contributing factors (system related) Frequent interruptions and distractions -A distracting environment in which nurses prepare medications [23] -Running multiple infusions at once [24,27] -Air-in-line alarms or clearing air [24] -Error-prone ICU environment due to the heavy workload and complex critical care [37] Training -Education on chemotherapy errors [22] -Mandatory end-user of smart IV pump training [24] -Education/training [36] -Lack of appropriate training [23] Assignment or placement of a health care provider or inexperienced personnel -Ward-based pharmacist [36] -Nurses with < 6 years of experience [40] deficit, " "miscalculation of or infusion rate, " and "stress (high-volume workload)" in this category.Half of these factors are related to the "performance deficit." Barriers identified in two or more studies were tubing misplacement [24,35] and non-compliance with protocols and guidelines [2,25], all of which belonged to the "performance deficit." Additionally, the high workload and environmental characteristics of the ICU, which corresponded to the "stress, " were also identified as barriers to rate control of IV medications [23,37].

Design
Most factors in this category were related to IV medication infusion devices such as infusion pumps and smart pumps.In the study by Lyons et al., the use of devices, such as patient-controlled analgesia pumps and syringe drivers, was a facilitator of rate control of IV medications [33].In addition to the use of these devices, the expansion of capabilities [26], monitoring programming [27], and standardization [22] were also facilitators.Unexpected equipment faults, a barrier, were identified in five studies [2,20,25,35,38].Moreover, the complex design of the equipment [23,24] and incomplete drug libraries in smart pumps [33,35] were identified in two studies each.Factors such as the misassembly of an unfamiliar infusion pump [21] and smart pumps not connected to electronic systems [30] were also barriers.

Contributing factors (system related)
The factors belonging to the "frequent interruptions and distractions" in this category were all barriers.Specifically, running multiple infusions at once [24,27], air-in-line alarms, or cleaning air [24] were identified as barriers.Among the facilitators of the "training, "

Categories by NCC MERP a Sub-categories Facilitators Barriers
Policies and procedures -Development of protocols for administering cytotoxic agents to nurses [22] -Providing information access [22] -Developing policy and procedure for standardizing overfill for infusion pump preparations and error follow-up [22] -Applying the FMEA method when introducing a smart IV pump [24] -Double-checks throughout the process [22,24,28,36] -Using preprinted drug labels to identify tubing above and below the IV pump when running multiple infusions at once [24] -Continuous incidence reporting and subsequent prevention strategies [28] -Limiting the use of handwritten orders to emergency cases only [28] -Visual timers for IV pushes, no interruption zone with motionactivated indicators, speaking aloud, and reminder signage [31] -Use of point and calling method [39] -Use of infusion safety intervention bundle [34] -Standardized concentration and pre-printed label [36] -Standardized plan for dose tapering and infusion scheme [36] -Absence of hospital policy that specifies a standard for KVO rate [30,32] -Absence of a culture that promotes the use of smart pumps for all IV administrations [32,33] -Medication orders that specified a duration rather than a rate [33] -Administering fluids for KVO at a low rate in anticipation of another infusion being needed [33] -Lack of automated infusion pumps [2] Communication systems between healthcare practitioners -Communication with physicians in instances of doubt [28] FMEA Failure mode and effects analysis, ICU Intensive care unit, IV Intravenous, KVO Keep vein open, NCC MERP National Coordinating Council for Medication Error Reporting and Prevention a Categories by NCC MERP: classified by medication error category according to NCC MERP [14] there were education and training on the use of smart pumps [24] and chemotherapy errors [22].There are two factors in the "assignment or placement of a HCP or inexperienced personnel, " where ward-based pharmacists were facilitators [36], but nurses with less than 6 years of experience were barriers [40].The sub-category with the most factors was "policies and procedures, " where the facilitators extracted in the four studies were doublechecks through the process [22,24,28,36].Among the barriers, two were related to keep-the-vein-open, which was identified in three studies [30,32,33].The lack of automated infusion pumps [2], the absence of culture for use [32,33], and problems in the drug prescription process [33] were also identified as barriers.Communication with physicians in instances of doubt identified was the only identified facilitator in the "communication systems between HCPs" [28].

Discussion
This scoping review provides the most recent evidence on the attributes of errors, facilitators, and barriers related to rate control of IV medications.The major findings of this study were as follows: (1) there were a few intervention studies that were effective in decreasing the errors related to rate control of IV medications; (2) there was limited research focusing on the errors associated with IV medication infusion devices; (3) a few studies have systematically evaluated and analyzed the severity of errors associated with rate control of IV medications; and (4) the facilitators and barriers related to rate control of IV medications were identified by NCC MERP taxonomy as three categories (human factors, design, and systemrelated contributing factors).
Among the nine project or experiment studies, only two interventions showed statistically significant effectiveness for IV rate control [28,31].Six studies did not report the specific statistical significance of the intervention [22,24,27,30,37,39], and one study found that the developed intervention had no statistically significant effect [34].In another study, administration errors, including rate errors, increased in the experimental group and decreased in the control group [37].IV rate control is a major process in medication administration that is comprehensively related to environmental and personal factors [3,41].According to previous studies, interdisciplinary or multidisciplinary cooperation is associated with the improvement in patient safety and decreased medical errors [42][43][44].Seven of the included studies were also project or experiment studies that developed interventions based on an interdisciplinary or multidisciplinary approach [22,24,28,30,34,37,39].Additionally, an effective intervention was developed by a multidisciplinary care quality improvement team [28].Therefore, it is crucial to develop effective interventions based on an interdisciplinary or multidisciplinary approach to establish practice guidelines with a high level of evidence related to IV rate control.
Of the 22 included studies, three identified potential problems associated with the use of IV medication infusion devices [26,32,35], and four described the application of interventions or explored the effects of the intervention developed to reduce errors that occur when using IV medication infusion devices [24,27,34,39].IV medication infusion devices, such as infusion pumps and smart pumps, are widely used in healthcare environments and allow more rigorous control in the process of administering medications that are continuously infused [45].Smart pumps are recognized as useful devices for providing safe and effective nursing care [15].However, the use of IV medication infusion devices requires an approach different from traditional rate monitoring by counting the number of fluid drops falling into the drip chamber [9].However, there exist many problems, such as bypassing the drug library, device maintenance, malfunction, tubing/connection, and programming in the use of IV medication infusion devices [32,35].None of the four studies that described the application of interventions or explored the effects of the intervention demonstrated statistically significant effects.All four studies had no control group [24,27,34,39] and two studies had only post-test designs [24,27].Therefore, further Table 4 Resolutions for the barriers rate control of intravenous (IV) medications suggested by the included studies BCMA Barcode medication administration, CPOE Computerized physician order entry, e-MAR Electronic medication administration record, FMEA Failure mode and effect analysis, HCP Healthcare providers a Categories by NCC MERP: classified by medication error category according to NCC MERP [14]

Categories by NCC MERP a
Resolutions for the barriers to rate control of IV medications Human factors -Appropriate monitoring and equipment check of the HCPs in the anesthetic department [20] -Supervision by a specialist and skilled assistance in the anesthetic department [20] -Rising anesthetists' awareness of the continued integrity of vascular access systems [21] -Checking correct tip placement and labels of lines by the HCPs in the anesthetic department [21] -Establishing a stronger pharmacology knowledge base for nursing students and nurses [38] -Raising HCPs' awareness to ensure appropriate setup, maintenance, and integration of smart pumps [35] Design -Supply products with a high safety standard by the manufacturers [23] -Short-term and long-term software and hardware changes to address failure modes with the new infusion pump [24] -The use of the appropriate site-specific drug profile through the new infusion pump [24] -Integration with barcoding and CPOE with the smart pump [26] -Incorporating real-time vital signs and laboratory data with the smart pump [26] -Automating monitoring and titration tasks with the smart pump [26] -Careful development and testing of smart pumps [26] -Drug dictionary in smart pumps reviewed by interdisciplinary committee members routinely and maintained up-to-date, evidence-based practice [30] -Assessing smart pump logs by the biomedical engineering department [30] -Investigating either physical or mechanical issues or human errors related to smart pumps by the biomedical engineering department [30] -Using smart pumps as part of an integrated system with barcode scanning and interfacing with electronic systems and reducing reliance on gravity feed [33] Contributing factors (system related) -Coordinated approach from practitioners, regulators, and the pharmaceutical industry [23] -Training for end users of the new infusion pump [24] -Healthcare FMEA between multiple institutions for discussion of best practices among pediatric oncology centers [25] -Different safety systems tailored for outpatient and inpatient chemotherapy settings [25] -Increased communication between adult and pediatric chemotherapy delivery systems to prevent similar errors from occurring [25] -A multidisciplinary approach that involves a change in hospital culture [28] -Collaboration with pharmacists to implement evidence-based interventions [28] -Increased training and supervision of new nurse graduates [40] -More obstetricians and nurses during the night shifts [2] -Improving nurses' working procedures and implementing a clinical decision support tool that generates recommendations about adequate infusion rates [29] -Implementation of BCMA and e-MAR [29] -Integrated systems that are successfully implemented and utilized to get the full benefits of the safety system [30] -Reviewing reports related to smart pumps by the patient safety committee [30] -Hospital leadership working with a smart pump vendor to improve their products [30] -Changing work practices (taking more time for drug administration, using short infusions to administer some medication) [37] -Promoting a safety culture around medication, including drug preparation and administration [37] -Implementation of electronic prescribing systems, barcode medication administration, and pharmacist-led training program [37] -Multidisciplinary team with strong leadership endorsed by hospital managers for successful quality improvement [37] -Interventions that are more automated and less reliant on human memory and vigilance to prevent interruption-related errors [31] -Providing standard work conditions, such as a standard ratio of nurses to patients by hospital managers [38] -Improving the relationship between the nurses and physicians by hospital managers [38] -Facilitating the 24-h presence of clinical pharmacology experts for responding to medication questions by hospital managers [38] -Interoperability between currently implemented healthcare information technologies [32] -Implementation of point and calling methods and increasing compliance [39] -Development and implementation of the intervention bundle developed incorporating the expertise of the multidisciplinary research team [34] -A multidisciplinary approach when evaluating and procuring infusion pump [35] -A process to regularly collect safety-related-data, review the data, and create solutions to address pump-related concerns [35] -A multidisciplinary approach to identify and implement effective interventions to prevent medication-related harm in children [36] research needs to be conducted to analyze errors in rate related to IV medication infusion devices and develop effective interventions.
A few studies have systematically evaluated and analyzed the severity of errors associated with rate control of IV medications.Among the 12 studies that reported the severity of errors associated with rate control of IV medications, five studies used NCC MERP, an internationally validated and reliable tool for assessing error severity, and one study used the Severity Assessment Code (SAC) developed by the New South Wales Health Department.Six studies did not use tools to assess error severity.The term "error severity" means the degree of potential or actual harm to patients [46].Evaluating the severity of medication errors is a vital point in improving patient safety throughout the medication administration process.This evaluation allows for distinguishing errors based on their severity to establish the development of risk mitigation strategies focused on addressing errors with the great potential to harm patients [47,48].Specifically, errors associated with rate control of IV medications were categorized as A to E on the NCC MERP and to groups 3 and 4 on the SAC.Additionally, errors associated with rate control of IV medications caused direct physical damage [2,21] and necessitated additional medication to prevent side effects or toxicity [23].Therefore, as errors in rate control of IV medications are likely to cause actual or potential harm to the patient, research systematically evaluating and analyzing error severity should be conducted to provide the basis for developing effective risk reduction strategies in the rate control of IV medications.
Facilitators and barriers were identified as human, design, and system-related contributing factors.Among the human factors, "performance deficit" included failure to check equipment properly, tubing misplacement, inadequate monitoring, non-compliance with protocols and guidelines, and human handling errors with smart pumps.Nurses play a major role in drug administration; thus, their monitoring and practices related to IV medication infusion devices can influence patient health outcomes [3,49].A major reason for the lack of monitoring was overwork, which was related to the complex working environment, work pressure, and high workload [3,11,49].Moreover, two of the included studies identified high workload as a barrier to rate control of IV medications [23,37].Therefore, to foster adequate monitoring of rate control of IV medications, a systematic approach to alleviating the complex working environment and work pressure should be considered.
Most facilitators and barriers in the devices category were related to IV medication infusion devices.In particular, expanding pump capabilities [26], monitoring pump programming [27], standardization [22], and using a pump [33] can facilitate rate control of IV medications.However, unexpected equipment faults are significant barriers, as identified in five studies among the included studies [2,20,25,35,38].Moreover, the design [23,24], user-friendliness [21], connectivity to electronic systems [30], and completeness of drug libraries [33,35] are factors that can affect rate control of IV medications.Therefore, it is important to improve, monitor, and manage IV medication infusion devices so that they do not become barriers.Moreover, because rate errors caused by other factors can be prevented by devices, active utilization and systematic management of devices at the system level are required.
Although there are many benefits of infusion and smart pumps for reducing errors in rate control of IV medications, they cannot be used in all hospitals because of the limitation of medical resources.The standard infusion set, which is a device for controlling the rate of IV medication by a controller [9], is widely used in outpatient as well as inpatient settings [32].Devices for monitoring the IV infusion rate, such as FIVA ™ (FIVAMed Inc, Halifax, Canada) and DripAssist (Shift Labs Inc, Seattle, USA), which can continuously monitor flow rate and volume with any gravity drip set, have been commercialized [33].However, they have not been widely used in hospitals.Therefore, developing novel IV infusion rate monitoring devices that are simple to use, can be used remotely, and are affordable for developing and underdeveloped countries can help nurses to reduce their workloads in monitoring IV infusion rates and thus maintain patient safety.
Most facilitators and barriers were system-related contributing factors, most of which belonged to the "policies and procedures." In four studies, the absence of hospital policies or culture related to rate control of IV medications was identified as a barrier [2,30,32,33].Medication errors related to incorrect rate control are problems that should be approached from macroscopic levels, such as via institutional policies and safety cultures.Therefore, large-scale research including more diverse departments and institutions needs to be conducted.
The second most common categories in system-related contributing factors were "frequent interruptions and distractions" and "training." Although nurses experienced frequent interruptions and distributions during work, only one of the included studies was on interventions that were developed to create an environment with reduced interruptions [31].Additionally, four studies found that education for nurses who are directly associated with medication administration is mandatory [22][23][24]36].Therefore, education and a work environment for safety culture should be created to improve IV rate control.
Based on resolutions for barriers rate control of IV medications, key groups relevant to rate control of IV medications include HCPs, healthcare administrators, and engineers specializing in IV medication infusion devices.HCPs directly involved in the preparation and administration of IV medications need to enhance their knowledge of drugs, raise awareness for the importance of rate control of IV medications, and improve performance related to IV infusion device monitoring.Engineers specializing in IV medication infusion devices should develop these devices by integrating various information technologies used in clinical settings.Additionally, they should identify issues related to these devices and continuously enhance both software and hardware.Healthcare administrators play a crucial role in establishing and leading interdisciplinary or inter-institution collaborations.They should foster leadership, build a patient safety culture within the organization, and implement training, interventions, and policies for correct rate control of IV medications.Decreasing medication errors, including errors in IV rate control, is closely linked to the various key groups [50][51][52][53], and multidisciplinary collaboration is emphasized for quality care [54][55][56][57].Therefore, each key group should perform its role and cooperate for appropriate IV rate control within a structured system.This review has some limitations that should be considered.As there no randomized controlled trial in this review, the causal relationship between wrong rate errors and their facilitators or barriers could not be determined.Moreover, only limited literature may have been included in this review because we included literature published in English and excluded gray literature.Since we did not evaluate the quality of the study, there may be a risk of bias in data collection and analysis.Despite these limitations, this study provides a meaningful assessment of published studies related to rate control of IV medications.This contribution will provide an important basis for new patient safety considerations in IV medication administration when determining future policies and device development.

Conclusions
The findings of this review suggest that further research is needed to be conducted to develop effective interventions to improve the practice of IV rate control.Moreover, given the rapid growth of technology in medical settings, research on IV medication infusion devices should be conducted.Additionally, to establish effective risk reduction strategies, it is necessary to systematically evaluate and analyze the severity of errors related to the rate control of IV medications.Several facilitators and barriers to rate control of IV medications were identified in this review to ensure patient safety and quality care, interventions and policy changes related to education and the work environment are required.Additionally, the development of a device capable of monitoring the flow of IV medication is necessary.This review will be useful for HCPs, hospital administrators, and engineers specializing in IV medication infusion devices to minimize errors in rate control of IV medications and improve patient safety.

Fig. 1
Fig. 1 PRISMA flow chart for literature selection

Table 1
Characteristics of the included studies (n

Table 1 (
continued) ADE Adverse drug events, AIMS Australian Incident Monitoring Study, APN Advanced practice nurse, D data collection, DOM Department operation manager, DRP Drug-related problems, E Events, EMR Electronic medical records, FMEA Failure mode and effects analysis, HAM High-alert medications, I Intervention, ICU Intensive care unit IV Intravenous, NA Not applicable, NHS National Health Service, P Participants, PA-PSRS Pennsylvania Patient Safety Reporting System, PSU Post-surgical unit, RN Registered nurse, WM Ward manager

Table 2
Errors related to rate control of intravenous (IV) medications (n