Mitigating Risks Associated with Multiple IV Infusions

February 2010 - Present


Multiple sequential and concurrent intravenous (IV) infusions are common in most hospitals to infuse numerous fluids and/or drugs into a patient. These infusions are often delivered with large volume pumps through a combination of primary and secondary “piggyback” infusions on multiple pumps and channels.

Clinical experts and the HumanEra’s own experience, both clinically and in a simulated lab environment (see smart infusion systems study), have indicated that there is a high frequency of use errors related to the setup and administration of multiple IV infusions. For example, physical mix-ups with infusion lines, bags, and/or pumps/channels can result in an IV fluid being delivered at the wrong dose and potentially via the wrong access point. However, there is little research to date regarding the risks and potential mitigation strategies associated with multiple IV infusions.

In collaboration with the Institute for Safe Medication Practices Canada (ISMP Canada), the HumanEra team will conduct a variety of field work and experimental research to assess the risks involved in these processes, determine and validate mitigating strategies, and disseminate recommendations to health care institutions, policy makers, and infusion pump manufacturers.

This project was launched in February 2010 and is currently in progress.


Funding Agency

Health Quality Ontario

Project Sponsor

Dr. Tony Easty

Refereed Proceedings

Colvin, C., Baird, P., Easty, T., & Trbovich, P. (2013). Complex incident reporting systems and multiple IV infusions. AAMI Horizons, Human Factors & IT.

Colvin, C., Fan, M., Cheng, R., Pinkney, S., Sabovitch, S., Shier, A., Trbovich, P., Easty, A. (2011, Jun). Effectiveness of medical incident databases as tools for adverse event analysis. Proceedings of the Festival of International Conferences on Caregiving, Disability, Aging and Technology (FCCDAT)’s 34th Canadian Medical and Biological Engineering Conference (CMBEC34), [CD-ROM].

Research Reports

Pinkney S, Fan M, Chan K, Koczmara C, Colvin C, Sasangohar F, Masino C, Easty A, Trbovich P. Multiple intravenous infusions phase 2b: laboratory study. Ont Health Technol Assess Ser [Internet]. 2014 May;14(5):1-163. Available from:

Fan M, Koczmara C, Masino C, Cassano-Piché A, Trbovich P, Easty A. Multiple intravenous infusions phase 2a: Ontario survey. Ont Health Technol Assess Ser [Internet]. 2014 May;14(4):1-141. Available from:

Cassano-Piché, A., Fan, M., Sabovitch, S., Masino, C., Easty, A.C., Health Technology Safety Research Team, Institute for Safe Medication Practices Canada. Ont Health Technol Assess Ser [Internet]. 2012 May; 12(16):1-132. Available from:

Fan, M., Cassano-Piché, A., Cheng, R., Colvin, C., Koczmara, C., Pinkney, S., Sabovitch, S., Shier, A., Trbovich, P., White, R., Easty, A. (2010). Multiple intravenous infusions phase 1a: Situation scan summary report. Retrieved from: Multiple IV Infusions_Phase1a_SummaryReport

Colvin C. An exploratory study of the fundamental characteristics influencing the analysis and communication activities of health care incident reporting systems. University of Toronto. 2011. 192p. Available from:

Related Documents

Ontario Health Technology Advisory Committee (OHTAC). Multiple intravenous infusions phases 2a and 2b: OHTAC recommendation [Internet]. Toronto: Queen’s Printer for Ontario; 2014 May. 16 p. Available from:


University Health Network

Evidence Development and Standards, Health Quality Ontario

Ontario Health Technology Advisory Committee (OHTAC)

Institute for Safe Medication Practices (ISMP) Canada

HumanEra Team

Andrea Cassano-Piché

Caterina Masino

Sonia Pinkney

Patricia Trbovich

Rachel White

Katherine Chan (student)

Farzan Sasangohar (student)

Rossini Yue (student)

ISMP Canada Project Team

Christine Koczmara

Roger Cheng

Shirley Sabovitch

For more information about this project, contact:

Sonia Pinkney