HSIB: Risks to medication delivery using ambulatory infusion pumps

The Health Services Investigation Bureau (HSIB)  has published an investigation report into Risks to medication delivery using ambulatory infusion pumps. We recommend all Faculty members and Pain Medicine professionals acquaint themselves with the details of the case and the report recommendations. 

Ambulatory infusion pumps are small, battery powered devices that allow patients to carry out day-to-day activities while receiving medication. They are used for many healthcare needs, including symptom relief during palliative care, and in different settings including hospitals, hospices, and patients' homes.

Despite having audio and visual warning alarms to notify when medication is not being delivered as it should be, there is a risk that alarms can go unnoticed, particularly by healthcare staff in inpatient settings.

Some of the safety risks identified are seen in the patient case the HSBI examine in the report. Stephen, a 45-year-old cancer patient on palliative care in hospital, did not receive his pain relief medication for six hours. Over the course of six hours, there were eight warnings.

The HSIB safety recommendations aim to develop national human factors guidance for infusion pumps and a mechanism to share medical device incident data. This is to support the safe use of the devices and prevent future occurrences of patients not receiving their medication as intended.