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Outdated Infusion Pump Software Risk

The British Columbia Patient Safety & Learning System (BCPSLS) recently reported a norepinephrine overdose caused in part by the infusion pump running an outdated version of the pump software. The updated software version contained a fix that would have helped prevent the error from occurring.

Additional information on the hospital’s interdisciplinary investigation can be found on the BCPSLS’s web site.

bcpslscentral.ca/patient-safety-case-study-inadvertent-overinfusion-of-norepinephrine/

While production of the Alaris 7130 Signature Edition pumps stopped in the United States in 2006, it is still being used across the USA and in Canada. BD/Carefusion is ending support for this pump.  According to a representative at BD/Carefusion, the parts and service for the Alaris 7130 Signature Edition ceased being available at the end of 2015 and they are discontinuing the IV infusion sets at the end of 2016. Please check with your Biomedical Department to see if your facility owns any of these pumps and see what your facility’s action plan is.

Key Takeaways:

  • Identify key stakeholders that should be involved in making decisions about the infusion pumps
  • Establish a process to review recalls, software and hardware update notices for infusion pumps
  • Identify what infusion pump models and software versions are currently in use
  • Investigate what the most up to date software versions are available for each type of infusion pump at your facility
  • Determine if and when you need to make updates

Do you have a story or incident to share related to infusion pump safety at your facility? In 2017, we are going to be taking a closer look at infusion pump incidents. Before sending us a story, please contact Jennifer Boehne at jboehne@chpso.org for transmission guidelines to ensure the confidentially of the information.