B Braun—Infusomat Space and Perfusor Space Infusion Pumps: Users May Unintentionally Bypass Drug Library
June 19, 2013 | Risk Management News
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In a May 17, 2013, Important Information letter submitted by an ECRI Institute member hospital, B Braun states that it has received reports of incidents in which clinicians unintentionally bypassed the drug library on the pumps below because they inadvertently assigned the drug name only rather than selecting the drug library with dose limits. B Braun states that the reported incidents involved the users programming rates of infusion, which were significantly higher than the intended dosage, resulting in over infusion. B Braun further states that the problem can occur when a clinician accesses the drug library from the Special Functions menu rather than at startup. When navigating to the drug library using the Special Functions menu and after selecting a drug, the user is prompted “Use preset values?” Answering “yes” at the prompt applies all drug library values, including limits. Selecting “no” applies a drug label only; this looks very similar to an infusion from the drug library (see figure 1 in the letter) but does not allow the clinician to program the pump in dose rate and does not offer the protection of the hard or soft limits of the drug library. B Braun states that this problem only affects Infusomat space infusion pumps or Perfusor space syringe pumps that have been set up to allow access to the drug library through the Special Functions menu. If you are not using the drug library or have disabled access to the drug library through the Special Functions menu, the problem does not affect your pumps. ....