Hospitalized patients receive countless doses of medications through manually programmed infusion pumps. Many medication errors are the result of programming incorrect pump settings. When used appropriately, smart pumps have the potential to detect some programming errors. However, based on the current use of smart pumps, there are conflicting reports on their ability to prevent patient harm without additional capabilities and interfaces to electronic medical records (EMR). We developed a smart system that is connected to the EMR including medication charting that can detect and alert on potential pump programming errors. Acceptable programming limits of dose rate increases in addition to initial drug doses for 23 high-risk medications are monitored. During 22.5 months in a 24 bed ICU, 970 alerts (4% of 25,040 doses, 1.4 alerts per day) were generated for pump settings programmed outside acceptable limits of which 137 (14%) were found to have prevented potential harm. Monitoring pump programming at the system level rather than the pump provides access to additional patient data in the EMR including previous dosage levels, other concurrent medications and caloric intake, age, gender, vitals and laboratory results.