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Improving infusion device safety

Improving infusion device safety
Reference number
0046
Central Alert System (CAS) reference
Safer Practice Notice 01
Issue date20 May 2004
Action date (if applicable) (date field)31 March 2005
TypeAlert

This Safer Practice Notice advises NHS organisations providing acute care in England and Wales to review the way they purchase, manage and use infusion devices.


Fifteen million infusions are performed in the NHS every year. The vast majority are delivered safely. However, at least 700 unsafe incidents are reported annually, of which 19 per cent are attributed
to user error.

A pilot study by the National Patient Safety Agency (NPSA) has helped to confirm the causes of incidents where the equipment does not appear to be faulty. These are:

 

  • trusts have a wider range of infusion device types than necessary;
  • trust have too many infusion devices with a higher specification than necessary;
    staff training is not a priority or competency-based; and
  • devices of the same type have multiple configurations and react differently under the same circumstances.

 

NHS organisations providing acute care in England and Wales are advised to:

 

  • review how purchasing decisions are made;
    evaluate the need for an infusion device before it is purchased;
  • reduce the range of infusion device types in use and, within each type, have agreed default configurations; and
  • investigate the benefits of a centralised equipment library.

 

The NPSA has developed a toolkit to help NHS organisations review their existing device management systems, and to assess potential cost benefits and improved patient safety.

 

Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.
Improving infusion device safety
Improving infusion device safety - 138 KB 0046 - Improving infusion device safety - Safer Practice Notice - 2004-05-20 - V1
Improving infusion device safety - summary - CY
Improving infusion device safety - summary - CY - 23 KB 0046A - Improving infusion device safety - summary - Safer Practice Notice - 2004-05-20 - V1 - CY
Standardising and centralising improving infusion devices
Standardising and centralising improving infusion devices - 616 KB 0046B - Standardising and centralising improving infusion devices - Full evaluation report - 2004-05 - V1
Improving infusion device safety
Improving infusion device safety - 23 KB 0046C - Improving infusion device safety - summary - Safer Practice Notice - 2004.05.20 - V1