HSIB: Investigation into the procurement, usability and adoption of ‘smart’ infusion pumps (3 December 2020)

Summary

This Healthcare Safety Investigation Branch (HSIB) report charts the emerging patient safety risks that can come with the introduction of ‘smart’ infusion pump technology into hospitals.

Smart infusion pumps are the latest generation of programmable devices that administer medication. They are seen as a way of improving safety as the smart functionality aims to prevent underdoses or overdoses – they are equipped with features such as alerts or alarms to help detect problems.

The investigation was launched after one NHS Trust recorded three incidents where a smart infusion pump delivered an overdose of fentanyl, a powerful pain medication. The patients weren’t harmed as it was swiftly picked up, however it emphasised the new risks that come with introducing new technology and the potential for serious medication errors.

The investigation focused on the barriers to implementing the technology effectively across the NHS, rather than on the technology itself.

Content

Implementation challenges

The investigation highlighted the main implementation challenges. This includes:

• National consistency in drug libraries – smart infusion pumps have an inbuilt dose error reduction system (DERS) which requires the use of a drug library. The investigation found that drug libraries were developed ‘locally’ and that there is no agreed national drug library for use in NHS. They also found that there is no national guidelines or standards on how to implement the libraries.
• Significant changes in processes – introducing the technology requires significant changes to prescribing and administration processes in trusts. The investigation found that procedure and guidance documents often needed updating, and variations in medication practice were ‘locally managed’ and were rarely shared within and between hospitals.
• Provision of specialist IT support and infrastructure – substantial IT infrastructure is needed to support the integration of smart pump technology. Software is needed to upload the drug library to smart pumps, download data logs (including any errors detected) and monitor the status of each smart pump. The investigation highlighted that maintaining the required IT infrastructure required specialist staff roles and often a new skill set.

The investigation found that the implementation of smart pump functionality would benefit from the use of risk management practices, as requirements are complex and similar to the introduction of a new IT system. Existing NHS Clinical risk standards could provide a basis for both manufacturers and trusts to work together to manage risks.