objectives of canadian infusion pump survey to explore the existing level of infusion pump problems...
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Objectives of Canadian Infusion Pump Objectives of Canadian Infusion Pump SurveySurvey
To explore the existing level of infusion pump problems in Canadian Hospitals
To obtain data on pump problems experienced in Canadian Hospitals
To prioritize infusion pump issues To develop strategies for safer infusion
pump use equipment and practice
ISMP Canada Infusion Pump Safety Project
Pump Problems Encountered (n=340)
85(25%)
255(75%)
0
50
100
150
200
250
300
No YesResponse
Nu
mb
er o
f R
esp
on
ses
ISMP Canada Infusion Pump Safety Project
Pump Problems Encountered by Hospital Type (n=340)
3 (50%)6 (14.6%)
34 (22.8%)
42 (29.2%)
102 (70.8%)
115 (77.2%)
35 (85.4%)
3 (50%)
0
20
40
60
80
100
120
140
Community (Non-Teaching)
Community (Teaching) Teaching Unknown
Hospital Types
Nu
mb
er
of
Re
sp
on
se
s
No Problems (Total = 85) With Problems (Total = 255)
ISMP Canada Infusion Pump Safety ProjectTop 10 Pump Problems (n=340)
91
6965
52 52 50
148 147
99 97
0
20
40
60
80
100
120
140
160
False
Air
in L
ine
Flow R
ate-
Inco
rrect
Rat
e
Flow R
ate-
OD
Tubing p
ositio
n-Fre
e Flo
w
Flow R
ate-
Fre
eflo
w
Stopped
/ Shut O
ff
Syrin
ge In
corre
ctly
Engag
ed
Door Open
Batte
ry F
ailu
re- N
o Ala
rm
No Fre
e Flo
w Mec
hanis
m
Major Problem Types
Nu
mb
er o
f R
esp
on
ses
ISMP Canada Infusion Pump Safety ProjectPump Problems Reported in Percentages
22.9
42.9
58.2
38.8
43.9
28.6
47.1
57.9
35.6
47.4
0
10
20
30
40
50
60
70
Free Flow Flow Rate Over Dose Air Sensor Other
Major Problem Types
Nu
mb
er o
f R
esp
on
ses
(%)
Total Aggregate (n=340) Ontario Responses (n=98)
ISMP Canada Infusion Pump Safety ProjectTop 5 Desired Pump Improvements (Total=231)
88
118 115 112
93
0
20
40
60
80
100
120
140
A B C D E
Nu
mb
er
of
Re
sp
on
se
s
Type of ImprovementA. On screen programming instructionsB. Protocol programming C. Ability to program clinical minimum/maximum drug concentrations or dosing parametersD. Clarity of displayE. Ability to program ‘primary’ versus ‘secondary” infusion rates
Comments ReceivedComments ReceivedFree Flow (26): “set removed from pump without clamping” Tubing:
“if tubing is removed incorrectly during cleaning damage may occur with pieces of tubing not visible remaining inside mechanism. If new tubing inserted freeflow situation can occur”
“tubing stretched out too much” “Free flow mixing with primary and secondary
IV dose occur”
Comments ReceivedComments ReceivedOverdose (23): “set removed without clamping” “with a CADD pump” Equipment:
“defective part”“dirty detection sensor”“failure of pumping mechanism-too much fluid
went through in a short time, one time” “Pump programmed in mLs/ min instead of mLs/ hr”
Overdose continued: “Epidural concentration set at peripheral rate” “…when there are too many lines and nurse
confuses the settings.” “tubing not positioned properly in pumping
mechanism” “...syringe loaded incorrectly and pump read
incorrect size of syringe and continued to infuse.”
Comments Received
Incorrect Flow Rate (34): Battery “suspected source undetermined” “patient initiated” “primary infusing instead of secondary” EMI Equipment
Comments Received
Incorrect Flow Rate continued: “PCA-wrong end of tubing attached to
medication bag-pump did not alarm” Incorrect input of medication concentration “Lines switched to wrong channel” “Problem with one brand of syringes which
was used in the syringe pumps. Pump would miscalculate syringe size….”
Comments Received
False Air in Line (16): “have had incidents where the tubing
was completely empty and the alarm didn't go off and other times, the alarm would go off because of a tiny bubble of air hardly visible to the human eye”
“false air in line alarm ,especially when running albumin”
Comments Received
Smart PumpsSmart Pumps
Medley by Alaris Medical Systems Colleague CX by Baxter Healthcare
Corporation B. Braun