In critical care environments where nurses manage multiple infusions under time pressure, infusion-related medication errors are unfortunately common—and often preventable. These errors can have devastating consequences, not only for patient safety but also for clinician confidence, team morale, and institutional liability.
Despite the rise of electronic health records and barcode scanning, the last mile of medication administration—IV line labeling and pump setup—remains vulnerable to human error. Here are three real-world scenarios that highlight these vulnerabilities, followed by a review of how Vigilant’s Verify platform can prevent such events.
Incident 1: The Disconnected Levophed Line
A patient in the ICU was receiving Levophed (norepinephrine) to maintain critical blood pressure. Alongside it, the patient was also receiving IV antibiotics. During a line adjustment, the nurse—intending to remove the antibiotic—accidentally disconnected the Levophed line. The result was immediate hemodynamic instability requiring emergency intervention.
Root cause: The nurse was unable to confidently trace the lines due to lack of clear, consistent labeling, especially at the pump and patient access points.
Incident 2: Starting the Wrong Pump – Opioid vs. Fluids
In another case, a nurse was managing several lines but had not labeled them during setup. She intended to start a Lactated Ringers (LR) infusion for hydration but accidentally started an opioid PCA pump instead. The patient, who did not require pain medication at that moment, began receiving opioids—triggering oversedation and requiring reversal agents.
Root cause: No visible or legible label to distinguish which medication was connected to which pump, combined with a cluttered pump station.
Incident 3: High-Concentration Morphine Confusion
In a third event, a patient’s morphine infusion had been prepared at 4× the standard concentration for titration purposes. During shift change, a nurse unfamiliar with the preparation assumed it was standard strength and started the infusion without adjusting the rate. The patient received a dangerously high dose within minutes and required a rapid response.
Root cause: Lack of standardized, automated labeling with concentration warnings. The syringe was labeled manually, and the writing was either unclear or overlooked.
The Solution: Vigilant’s Verify Platform
These incidents all stem from a shared issue: insufficient, inconsistent, or absent labeling of IV lines and pumps. Vigilant’s Verify platform was designed precisely to solve these vulnerabilities by digitizing and automating IV labeling at the point of care.
1. Automated, Standardized Labels
With just two barcode scans (nurse badge + drug NDC), the system prints:
- Three-part labels for each infusion: IV bag, pump tubing, and patient access site
- Color-coded, Tall Man lettering for high-risk or look-alike medications
- Concentration, start time, and change time—all clearly printed
2. Line Tracing Made Simple
Clear labels at both ends of the tubing eliminate guesswork, making it easy to trace the correct line, even during a handoff or emergency.
3. High-Risk Drug Alerts
Labels can include custom alerts for medications like opioids or concentrated infusions. For example, “MORPHINE 4×” is printed in bold red text, preventing dangerous misidentification.
4. Rapid Setup, No IT Required
The system is plug-and-play, requiring no IT infrastructure or downtime. Most units achieve full adoption in under an hour, making it a low-friction, high-impact upgrade.
Outcomes You Can Expect
Hospitals using Vigilant’s platform have reported:
- Zero CLABSIs post-implementation in multiple ICUs【IU Health Poster】
- 639 consecutive CLABSI-free days at WellStar using Vigilant-integrated workflows【WellStar Publication】
- Up to 95%+ IV labeling compliance in units with previous documentation gaps
Final Thoughts
Infusion-related medication errors aren’t due to negligence—they’re the product of broken systems relying too much on human memory and manual workflows. By automating IV labeling with Vigilant’s Verify platform, hospitals can drastically reduce these risks and give nurses the tools they need to focus on what matters most: safe, confident patient care.
Every nurse has a story like the ones above. The question is: how long can we afford to wait before modernizing one of the most dangerous gaps in clinical practice?