From the May 6, 2004 issue

We recently heard about several ten-fold dosing errors caused by close proximity of the "zero" and "decimal point" keys on IV pumps. Thankfully, none of the patients were injured. In each case, the nurse had inadvertently pressed the "zero" instead of the "decimal point" key when programming the dose. Certainly, transposition of keys located next to one another is a common problem, whether it's with IV pumps, telephones, calculators, and other devices with keypads. But it would be safer to locate the decimal point key far away from any numeric key, especially a zero, to help avert serious programming errors. If your pumps possess this design flaw, alert staff to the potential for errors and be sure to include an independent double check of programmed doses for high-alert medications. New "smart pumps," which recognize preset dose limits, would alert nurses to these errors before the infusion starts.