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Award-winning medical detective work improves patient safety worldwide


Contributed by Jane Campbell, Provincial Health Services Authority

A multidisciplinary team from Vancouver Coastal Health (VCH) and Lower Mainland Biomedical Engineering (LMBME) have received the Health Devices Achievement Award from ERCI recognizing their work to pinpoint a flaw in infusion pump tubing sets, making health care safer for patients all over the world. ERCI is a non-profit organization that promotes medical technology safety.

The investigation started after a series of troubling incidents. Infusion pumps, which deliver medications to patients gradually over a period of time, were suspected to be malfunctioning and administering medications much more quickly than intended. This potentially dangerous situation occurred more than thirty times at health-care facilities across B.C.

After recognizing the high number of over-infusion incidents involving these pumps, Vancouver Coastal Health (VCH) Professional Practice partnered with colleagues at Lower Mainland Biomedical Engineering (LMBME) to examine these incidents and find the root cause of the failures so they could be prevented in the future. The results of their in-depth 10-month investigation led to a global recall of millions of infusion pump tubing sets.

To minimize any potential risks to patients while the investigation was underway, the team educated staff about the problem, offered guidance on how to reduce the risks, and asked staff to remove pumps involved in any incidents from use so they could be examined.

"This was a really uncertain time for our nurses not knowing if or when one of their infusions would over-infuse, which depending on the medication could harm their patient," explains Sarah Hawley, Practice Initiatives Lead at VCH Professional Practice. "The efforts our nurses undertook to monitor for this issue and report these events was a big part of being able to solve the problem." 

Using the evidence collected by bedside nurses, LMBME worked with ECRI and the pump manufacturer to examine the infusion set up — including the tubing. This led to the critical discovery of a flaw in the machine's tubing that could, under certain circumstances, cause medication to be administered too quickly to the patient.

Based on these findings, the manufacturer issued a global recall of the tubing sets that affected millions of units all over the world.

"LMBME works throughout the B.C. health-care system to ensure medical devices are as safe and effective as possible," says Carol Park, LMBME Executive Director. "The investigation of these infusion pumps is a wonderful example of how LMBME can make a real difference in patient safety by collaborating with frontline clinical staff to proactively respond to and solve problems with medical equipment."

Brendan Gribbons, Regional Engineering Team Manager of LMBME, explains that equipment flaws like these are typically discovered by manufacturers, not by teams working within the health-care system.

"The collaborative effort between VCH and LMBME during the investigation led to our identifying the tubing defect before the manufacturer," says Brendan. "This unprecedented discovery contributed towards improving patient safety on a global scale, and potentially explains years of unexplained over-infusions."

Brittany Watson, VCH Director of Professional Practice, notes the project was able to succeed because of the cooperation and involvement of many people and organizations.

"I am so proud of what this team accomplished," says Brittany. "This award recognizes the hard work of many different people including frontline nurses and physicians, the LMBME team, Quality and Patient Safety, Risk and Professional Practice, and operational and clinical leaders. The exceptional teamwork that made this investigation possible shows the strength of the commitment to patient safety throughout the health-care system in B.C."

SOURCE: Award-winning medical detective work improves patient safety worldwide ( )
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