BD Alaris Pump shut off
ISMP and ECRI have updated an alert warning about damaged BD Alaris Inter-Unit Interface (IUI) connectors on the Alaris Pump modules that can result in medication infusions suddenly stopping. Damage to the IUI connectors, which attach the modules of the Alaris System together, may result in an interrupted electrical communication between a module and the PC unit or the pump "brain." As a result, the pump modules may display a "communication error" or shut down with a channel disconnect alarm on the PC unit. When this occurs, the infusion may stop without warning until the module(s) are restarted or replaced. Over the past few years, ECRI and ISMP have continued to receive reports involving IUI connector problems, some of which have resulted in patient harm.
A patient was receiving several I.V. infusions including norepinephrine and vasopressin through a BD Alaris infusion pump. A nurse noticed a significant decrease in the patient's BP and went to adjust the norepinephrine infusion rate. When the nurse touched the channel that the norepinephrine was running through, it turned off, and so did the channel that delivers the vasopressin. The patient continued to decompensate and required CPR. The healthcare team acquired new channels and restarted the norepinephrine and vasopressin infusions, but the patient expired.
During the event investigation, other nurses in the organization stated that there have been prior occasions when they received a "communication error" warning on a pump, but they had not reported the problem. In this most recent event, the pump was sequestered and sent to BD for evaluation. The company determined that the cause of the malfunction was corrosion and blue or green deposits possibly from cleaning residue left on the pins in the IUI connector. BD recommends inspecting IUI connectors on each device before every use and if any surface contaminants or cracks are visible, the device should be sent to clinical/biomedical engineering to replace the IUI connector (see IUI connectors). It is also important to review resources provided by BD to facilitate appropriate cleaning. If your organization uses BD Alaris infusion pumps, consider the following additional recommendations:
* Share this information with healthcare staff and those who clean the pump modules.
* When connecting a pump module, ensure that it is firmly connected.
* If a PC unit displays a "communication error" warning, report per the organizational policy and sequester the PC unit, incident module, and all other modules attached at the time of the incident from service and notify clinical/biomedical engineering. Do not detach the modules.
* Educate central supply and those who clean pump modules to only use approved cleaning methods and chemicals as outlined by BD. Do not connect the pump modules when the device is wet from cleaning solutions.
* Store modules individually (not connected to each other or the PC unit) when not in use.
* Develop a process for clinical and biomedical engineering to inspect IUI connectors for damage (cracks or deposits) during preventive maintenance and when a problem is reported. If damage is visible in an IUI connector, biomedical engineering should replace the connector.
* Establish a replacement schedule for IUI connectors based on failure history. If the failure rate of the IUI connectors is high or increasing, contact your BD representative to discuss appropriate cleaning practices and IUI replacement.
* While IUI damage is a common reason to receive this warning, there may be additional failure modes that can cause a "communication error" to occur (inappropriate module latching, stuck latch assembly) that should be considered.
Error-prone abbreviations
Unfortunately, some FDA drug databases may list unsafe abbreviations and dosage units on the ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations and The Joint Commission Official "Do Not Use" List. This includes "ug" for micrograms rather than mcg, "U" and "IU" rather than spelling out units, and listing the strength without a leading zero, such as ".4 mg" rather than 0.4 mg. The FDA should remove and eliminate the use of error-prone abbreviations in their drug databases since healthcare professionals use it as a drug information resource.