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Safer ambulatory syringe drivers

Reference number
1287
Central Alert System (CAS) reference
NPSA/2010/RRR019
Issue date16 December 2010
Action date (if applicable) (date field)16 December 2011
DH Gateway reference
14877
TypeAlert

While the majority of syringe drivers and pumps used in healthcare have rate settings in millilitres (ml), some older types of ambulatory syringe drivers have rate settings in millimetres (mm) of syringe plunger travel. This is not intuitive for many users and not easy to check. Errors include the wrong rate of infusion caused by inaccurate measurement of fluid length or miscalculation or incorrect rate setting of the device.


NHS organisations should :

1. Develop a purchasing for safety initiative that considers the following safety features before ambulatory syringe drivers are purchased:
a) rate settings in millilitres (ml) per hour;
b) mechanisms to stop infusion if the syringe is not properly and securely fitted;
c) alarms that activate if the syringe is removed before the infusion is stopped;
d) lock-box covers and/or lock out controlled by password;
e) provision of internal log memory to record all pump events.

2. Agree an end date to complete the transition between existing ambulatory syringe drivers and ambulatory syringe drivers with additional safety features (as soon as locally feasible, and within five years of this RRR).

3. Take steps to reduce the risks of rate errors while older designs of ambulatory syringe drivers remain in use, based on a locally developed risk reduction plan which may include: raising awareness, providing information to support users with rate setting, and using lock-boxes.

4. Take steps to reduce the risks during any transition period when both types of design are in use, including:
a) reviewing and updating policies and protocols to include the safe operation of all designs of ambulatory syringe driver in local use;
b) revising user training programmes to include the safe operation of all designs of ambulatory syringe driver in local use.

Safer ambulatory syringe drivers RRR
Safer ambulatory syringe drivers RRR - 113 KB 1287 | Safer ambulatory syringe drivers RRR | Rapid Response R | 2010-12-13 | v1
Safer ambulatory syringe drivers supporting information
Safer ambulatory syringe drivers supporting information - 249 KB 1287 A | Safer ambulatory syringe drivers supporting information | Rapid Response Report | 2010-12-21 | v2
Safer ambulatory syringe drivers briefing for chief executives
Safer ambulatory syringe drivers briefing for chief executives - 55 KB 1287 B | Safer ambulatory syringe drivers briefing for chief executives | Rapid Response Report | 2010-12-15 | v1