Description of Event or Problem · 0
FOR THE ALARIS LARGE VOLUME INFUSION PUMPS MADE BY THE BECTON DICKINSON COMPANY, I NOTICED AN OVERSIGHT IN THE ALARM SOFTWARE THAT I BELIEVE POSES AN UNNECESSARY RISK TO PATIENTS. WHEN A MEDICATION'S "VOLUME TO BE INFUSED" (A VOLUME SET BY THE USER) HAS COMPLETED, THE PUMP AUTOMATICALLY STARTS ALARMING AND DROPS THE INFUSION RATE DOWN TO 20ML/HR FOR EVERY MEDICATION. THIS IS DANGEROUS WHEN THE PUMP IS INFUSING HIGH DOSE VASOPRESSORS (NOREPINEPHRINE, VASOPRESSIN, EPINEPHRINE, PHENYLEPHRINE, ETC.) WITH SHORT HALF LIVES. A SUDDEN DROP IN THESE MEDICATIONS' INFUSION RATES FOR EVEN A BRIEF PERIOD CAN CAUSE SIGNIFICANT HEMODYNAMIC INSTABILITY OR COMPROMISE IN CRITICALLY ILL PATIENTS. THE PUMP NEEDS TO ALARM PRIOR TO THE VOLUME TO BE INFUSED RUNNING OUT SO THAT HEALTHCARE STAFF CAN ADD VOLUME TO THE PUMP OR HANG MORE MEDICATION BEFORE THE INFUSION RATE SLOWS DOWN. THIS FUNCTION ALREADY EXISTS FOR THE SYRINGE PUMP VARIANT, AND IS KNOWN AS A "PRE-ALARM," BUT NEEDS TO BE EXTENDED TO ALL PUMPS FOR THESE SHORT-ACTING VASOACTIVE MEDICATIONS. ALSO, THE PUMP ALARM SOUND/PATTERN IS THE EXACT SAME REGARDLESS OF WHAT'S BEING INFUSED. I REACHED OUT TO BECTON DICKINSON SEVERAL TIMES ABOUT MAKING THE ALARMS FOR SHORT-ACTING VASOPRESSOR MEDICATIONS DISTINCT FROM OTHER ALARMS BUT HAVE NOT HEARD ANYTHING BACK. ALARM FATIGUE IS AN UNFORTUNATE BUT SERIOUS PROBLEM IN CRITICAL CARE AREAS. I WORK AS A BEDSIDE NURSE IN AN ICU AND HAVE WITNESSED NEAR-MISS EVENTS DUE TO IV PUMPS RUNNING VASOPRESSORS NOT BEING KEPT UP WITH. IF I'M IN MY PATIENT'S ROOM DOING SOMETHING, AND I HEAR A PUMP ALARM IN THE ROOM NEXT DOOR, I HAVE NO WAY OF KNOWING IF I NEED TO STOP EVERYTHING I'M DOING AND ADDRESS THAT PUMP IMMEDIATELY, OR IF I CAN TAKE A MINUTE TO FINISH MY TASK. HAVING A DISTINCT ALARM FOR THESE IMPORTANT MEDICATIONS WOULD LET ANYONE NEARBY KNOW THAT THEY MUST ADDRESS THAT PUMP IMMEDIATELY. EVEN IF A NURSE IS UNFAMILIAR WITH THE PATIENT, THEY WILL KNOW THAT A VASOPRESSOR IS RUNNING LOW/OUT OF VOLUME AND MUST CHECK THE PUMP AS SOON AS POSSIBLE. I BELIEVE FIXING THIS OVERSIGHT AND ADDING THE SAFEGUARD OF A DISTINCTIVE "IMPORTANT MEDICATION" ALARM (EVEN IF IT'S JUST AN OPTION THAT HOSPITAL SYSTEMS CAN CONFIGURE HOW THEY WANT) WILL GO A LONG WAY IN IMPROVING PATIENT SAFETY. INTENSIVE CARE UNIT (ICU).