Improving the safety of drug delivery

Hospitals, care homes and nursing homes across the country use ambulatory syringe drivers regularly to deliver vital opioids and other palliative care medicine routinely to patients. However, a National Patient Safety Agency (NPSA) report previously found evidence of harm to patients caused by the use of some older style ambulatory syringe drivers. As over-infusion can cause death, while under-infusion can cause pain and distress, the NPSA issued an alert calling for all older style syringe drivers to be replaced over time. The NPSA Rapid Response Report – RRRO19 – Safer Ambulatory Syringe Drivers – highlighted several issues connected with older types of syringe drivers which have led to patient safety issues and even the death of patients. Between 1 January 2005 and 30 June 2010, the NPSA received reports of eight deaths and 167 non-fatal incidents involving ambulatory syringe drivers.1 The key problem highlighted by the NPSA, was that some older types of ambulatory syringe drivers had rate settings in millimetres (mm) of syringe plunger travel, instead of millilitres (mL). The use of millimetres as a basis for medication calculation is unique to ambulatory syringe drivers so is not intuitive to many users. According to the NPSA, errors have occurred due to incorrect infusion rates from inaccurate measurement or miscalculation or incorrect rate setting of the device. Another issue highlighted has been that some models use mm per hour while others use mm per 24 hours. The Rapid Response Report (RRR) was issued in December 2010, and required all NHS and independent sector users of ambulatory syringe drivers to develop a ‘Purchasing for Safety Initiative’ that considered the following safety features when purchasing new syringe drivers:

• Rate settings in millimetres per hour.
• Mechanisms to stop infusion if the syringe is not properly and securely fitted.
• Alarms that activate if the syringe driver is removed before the infusion is stopped.
• Lock box covers and or lock out controlled by password.
• Provision of internal log memory to record all pump events.

The report also required organisations to agree an end date to complete the transition between existing syringe drivers and ones with the safety features, as soon as possible, and within five years of the RRR, which was issued on 16 December 2010. Organisations are required to take steps to reduce risks to patients during any transition process which might see both older and new pumps in use at the same time, and to ensure that all staff are fully trained in the safe operation of all ambulatory syringe drivers. All NHS and private organisations using ambulatory syringe drivers need to meet the NPSA requirements to help improve patient safety and reduce the risk of harm and even death. The NPSA pointed out the need to manage the transition process very carefully with risk measures in place to avoid issues where two types of pump might be in use at the same time. All eight of the fatalities highlighted in the review were caused by over infusion. Some of the other types of errors, which caused patient incidents while using the older ambulatory syringe drivers, included: