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infusion pump running an outdated version of the pump software.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.
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
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 email@example.com for transmission
guidelines to ensure the confidentially of the information.