DOPA-CONC-ERR-001 medical data_error ai_generated true

AI miscalculates IV pump rate for dopamine infusion using wrong concentration factor, leading to potential overdose

ID: medical/iv-pump-rate-calculation-error

Also available as: JSON · Markdown · 中文
90%Fix Rate
88%Confidence
1Evidence
2024-01-20First Seen

Version Compatibility

VersionStatusIntroducedDeprecatedNotes
Alaris PCU v6.0 active — — —
Baxter Sigma Spectrum v8.1 active — — —
Braun Infusomat Space v2.5 active — — —

Root Cause

Dopamine is typically supplied as 400 mg/250 mL (1.6 mg/mL) or 800 mg/250 mL (3.2 mg/mL), but AI assumes a standard concentration of 1 mg/mL, causing a 60% or 220% error in infusion rate calculation for common dosing (5-20 mcg/kg/min).

generic

中文

多巴胺通常以400毫克/250毫升（1.6毫克/毫升）或800毫克/250毫升（3.2毫克/毫升）供应，但AI假设标准浓度为1毫克/毫升，导致常见剂量（5-20微克/千克/分钟）的输注速率计算出现60%或220%的错误。

Official Documentation

https://www.uptodate.com/contents/dopamine-drug-information

Workarounds

  1. 90% success Always verify IV drug concentration from pharmacy label before programming pump; use a standardized calculator like 'MedCalc' or 'MDCalc' that requires both drug amount and diluent volume 
    Always verify IV drug concentration from pharmacy label before programming pump; use a standardized calculator like 'MedCalc' or 'MDCalc' that requires both drug amount and diluent volume
  2. 85% success Implement a two-nurse verification protocol: one calculates, the other independently recalculates using a different method (e.g., infusion rate = (dose x weight x 60) / concentration) 
    Implement a two-nurse verification protocol: one calculates, the other independently recalculates using a different method (e.g., infusion rate = (dose x weight x 60) / concentration)
  3. 95% success Use smart pump drug library (e.g., Alaris Guardrails) that auto-calculates rate based on selected drug and concentration; override only after double-check 
    Use smart pump drug library (e.g., Alaris Guardrails) that auto-calculates rate based on selected drug and concentration; override only after double-check

中文步骤

  1. Always verify IV drug concentration from pharmacy label before programming pump; use a standardized calculator like 'MedCalc' or 'MDCalc' that requires both drug amount and diluent volume
  2. Implement a two-nurse verification protocol: one calculates, the other independently recalculates using a different method (e.g., infusion rate = (dose x weight x 60) / concentration)
  3. Use smart pump drug library (e.g., Alaris Guardrails) that auto-calculates rate based on selected drug and concentration; override only after double-check

Dead Ends

Common approaches that don't work:

  1. 70% fail

    Pump programming is often correct; the error is in the concentration factor used in the calculation, not the pump entry itself

  2. 60% fail

    This concentration is rarely used in ICU; standard is 250 mL bags; using wrong volume compounds the error

  3. 55% fail

    The dose itself may be correct, but the rate-to-concentration conversion is flawed; proportional adjustment propagates the error