{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,12]],"date-time":"2025-12-12T13:33:59Z","timestamp":1765546439390,"version":"3.38.0"},"reference-count":27,"publisher":"SAGE Publications","issue":"1","license":[{"start":{"date-parts":[[2019,4,15]],"date-time":"2019-04-15T00:00:00Z","timestamp":1555286400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Health Informatics J"],"published-print":{"date-parts":[[2020,3]]},"abstract":"<jats:p> Many studies have highlighted the patient safety risks in intravenous medication administration, and various technological solutions have been proposed to mitigate those risks, including \u2018smart pumps\u2019 and closed-loop systems. Few studies describe these implementations in detail. In this article, we report on a sociotechnical investigation of a closed-loop documentation system linked with smart pumps for intravenous infusion administration on an intensive care unit. The smart pumps are \u2018mapped\u2019 to an electronic prescribing and medication administration system, allowing infusion rates, volumes and boluses of intravenous medication to be monitored in real time. Ethnographic observations were conducted over 37 h, including direct observation of infusion administration (n\u2009=\u200923 infusions), discussions with clinical staff and semi-structured interviews with intensive care unit managers (n\u2009=\u20092). Analysis was based on the Distributed Cognition for Teamwork (DiCoT) method to understand how information is processed across individuals, teams and technologies. We report on how the system works in context, and identify contributions and compromises to patient safety with new risks that need to be managed at bedside and intensive care unit level. <\/jats:p>","DOI":"10.1177\/1460458219839574","type":"journal-article","created":{"date-parts":[[2019,4,15]],"date-time":"2019-04-15T09:23:56Z","timestamp":1555320236000},"page":"576-591","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":9,"title":["The devil is in the detail: How a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety"],"prefix":"10.1177","volume":"26","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2114-4367","authenticated-orcid":false,"given":"Dominic","family":"Furniss","sequence":"first","affiliation":[{"name":"University College London, UK"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2892-1245","authenticated-orcid":false,"given":"Bryony","family":"Dean Franklin","sequence":"additional","affiliation":[{"name":"University College London, UK; Imperial College Healthcare NHS Trust, UK"}]},{"given":"Ann","family":"Blandford","sequence":"additional","affiliation":[{"name":"University College London, UK"}]}],"member":"179","published-online":{"date-parts":[[2019,4,15]]},"reference":[{"key":"bibr1-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2004.011957"},{"key":"bibr2-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1097\/00005110-200410000-00001"},{"key":"bibr3-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1007\/BF01739124"},{"key":"bibr4-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2015-009777"},{"key":"bibr5-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2017-007476"},{"key":"bibr6-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-018-3025-x"},{"key":"bibr7-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1007\/s001340101065"},{"key":"bibr8-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2015-004465"},{"key":"bibr9-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1097\/01.CCM.0000155912.73313.CD"},{"key":"bibr10-1460458219839574","doi-asserted-by":"publisher","DOI":"10.3233\/WOR-2012-0091-3850"},{"key":"bibr11-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1016\/j.jbi.2012.02.003"},{"key":"bibr12-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1155\/2015\/686598"},{"key":"bibr13-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1002\/jppr.1421"},{"key":"bibr14-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1093\/intqhc\/mzy042"},{"key":"bibr15-1460458219839574","doi-asserted-by":"publisher","DOI":"10.5603\/AIT.a2015.0069"},{"key":"bibr16-1460458219839574","first-page":"2","volume":"3","author":"De Journett L","year":"2017","journal-title":"J Intensive Crit Care"},{"key":"bibr17-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1093\/bja\/aet001"},{"key":"bibr18-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1002\/asjc.701"},{"key":"bibr19-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1016\/j.rcae.2013.05.003"},{"key":"bibr20-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2006.019497"},{"key":"bibr21-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1002\/jppr.1235"},{"key":"bibr22-1460458219839574","doi-asserted-by":"publisher","DOI":"10.7551\/mitpress\/1881.001.0001"},{"issue":"2","key":"bibr23-1460458219839574","first-page":"174","volume":"17","author":"Hollan J","year":"2000","journal-title":"ACM T Comput: Hum Int"},{"key":"bibr24-1460458219839574","first-page":"26","volume-title":"Interactive systems design, specification and verification","author":"Blandford A","year":"2005"},{"key":"bibr25-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1080\/00140130600612663"},{"key":"bibr26-1460458219839574","doi-asserted-by":"publisher","DOI":"10.1016\/j.jbi.2014.12.006"},{"key":"bibr27-1460458219839574","unstructured":"Furniss D, Mayer A, Franklin BD, et al. (submitted) Exploring structure, agency and performance variability in everyday safety: an ethnographic study of practices around infusion devices using distributed cognition."}],"container-title":["Health Informatics Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/1460458219839574","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/1460458219839574","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/1460458219839574","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,3,1]],"date-time":"2025-03-01T20:53:19Z","timestamp":1740862399000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/1460458219839574"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,4,15]]},"references-count":27,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2020,3]]}},"alternative-id":["10.1177\/1460458219839574"],"URL":"https:\/\/doi.org\/10.1177\/1460458219839574","relation":{},"ISSN":["1460-4582","1741-2811"],"issn-type":[{"type":"print","value":"1460-4582"},{"type":"electronic","value":"1741-2811"}],"subject":[],"published":{"date-parts":[[2019,4,15]]}}}