The team at Lower Mainland Biomedical Engineering (LMBME), which serves Providence Health Care, Fraser Health Authority, Vancouver Coastal Health

(VCH) and the Provincial Health Services Authority, partnered with colleagues at VCH to examine these incidents to find the root cause of the failures so they could be prevented in the future. They ultimately succeeded, and their findings led to a global recall of millions of infusion pump tubing sets.

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

After recognizing the high number of over-infusion incidents involving these pumps, LMBME and VCH started a ten-month multidisciplinary investigation to determine the cause of the problem and minimize any potential risks to patients in the meantime. They 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 when or if one of their infusions would over-infuse, which depending on the medication could potentially harm their patient,” explains Sarah Hawley, Practice Initiatives Lead at VCH Professional Practice. “The efforts taken by our nurses in monitoring for this issue and reporting these events was a big part of being able to solve it.”

With the evidence collected by nursing, LMBME was able to work with ECRI and the pump manufacturer to examine the infusion set up, including the tubing.

This led to the 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 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 all stakeholders involved with the investigation led to internal identification of the tubing defect before the manufacturer,” Brendan says. “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.

“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,”

Brittany says. “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.”

This page last updated Mar 1, 2021 1:44pm PST