Bottom line question to the group:

- has your institution reviewed and/or approved the usage of non-BD syringes for your smart infusion pumps?

More details below:

In the last few years, there have been recalls for both smart infusion pumps and syringes issued by the FDA. At our institution, our main smart infusion pump used is the BD Alaris system. Recently, BD Alaris pumps received full 510k FDA approval. These new pumps now have a more restrictive syringe and PCA compatibility list.

A NICU at one of our hospitals brought forward the concern that the 1 ml and 3 ml BD syringes are the same barrel size, so when they are inserted into the pump, the autodetect feature (Alaris syringe pump) cannot tell the difference and the nurse must manually select the syringe size. Due to the label on these smaller syringes, it is often hard to tell which size the syringe actually is.

Apparently mistakes/errors have happened more than once, and I wanted to see if anyone else has had this issue or any successful mitigation strategies?

Thank you

Interested in hearing if any sites which utilize BD Optima for home infusions, have encountered issues with their Infusion Clamps (N35-0, N40-0).

We’ve encountered situations where the clamp can be placed backwards, which can then force separation between injector and connector, and results in the pump not running correctly. We’ve engaged BD Carefusion on this topic, but would appreciate hearing from other sites if you’ve experienced this challenge as well.

Thank you,

Matt

Has anyone encountered a malfunction in the primary IV tubing with the secondary IVPB backglowing into the primary tubing and solution.

Here's what we know.

- 4 occurence with chemo agents

- The RNs had the primary set up, attached the secondary (primary tubing was in the pump but pump turned off). When the secondary was unclamped the medication from the secondary back flowed (past the back flow check valve) and into the primary solution rather quickly.

The secondary bag was higher than the primary.

Hello,

We recently had a near miss event at our institution where 2 patients with the same name (one Jr, one Sr.) almost received medications intended for the other patient.

Upon review, one of the gaps we identified was that the patient suffix does not display for nurses on Pyxis ES console. According to our BD Carefusion representative, the patient suffix information is transmitted over to Pyxis, but is information only and cannot be displayed for nursing at the console.