Investigation report: risks to medication delivery using ambulatory infusion pumps – design and usability in inpatient settings
The main finding set out in latest report from HSSIB is that alarms on a portable medical device may not notify staff that medication is not being delivered as it should, creating a ‘hazardous situation’ and increasing the risk of harm to patients.
Source:
Health Services Safety Investigation Body
SPS commentary:
The investigation focused on the delivery and monitoring of medication via ambulatory infusion pumps to provide continuous symptom relief medication for patients receiving palliative care in an inpatient setting. The investigation used a real patient safety incident to examine aspects of ambulatory infusion pump use, and provide safety recommendations to prevent future occurrences of patients not receiving their intended medication and to improve care across the NHS.
The reference case was prescribed medication for analgesia and anti-emetics delivered via ambulatory infusion pump. On the seventh day of his stay on the ward, there was an occlusion in the pump, during which he did not receive his symptom relief medication. The pump was fully functional, operating as designed, and providing the required visual and audible alerts, but hospital staff were not aware that medication was not being delivered. A subsequent coroner’s inquest report stated that ‘It is more likely than not that patient had intermittently silenced the alarm by pressing buttons on the syringe driver. This would have silenced the alarm without the occlusion being addressed.’