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National Patient Safety Agency

NPSA calls for safer ambulatory syringe drivers

Thursday 3 February 2011

The National Patient Safety Agency (NPSA) has issued guidance to NHS organisations in England and Wales, recommending that they phase out ambulatory syringe drivers*, with rate settings of millimetres (mm), within five years, to reduce the potential of harm to patients.


NHS organisations are being encouraged to replace ambulatory syringe drivers with rate of administration settings in mm in favour of safer ambulatory syringe drivers with rate settings in millilitres (ml). Ambulatory syringe drivers that have their rate settings in mm require manual calculation to set the correct rate of administration and this introduces the risk of error.


The ambulatory syringe drivers with rate settings in ml also have additional safety features such as alarms that activate if the syringe is not securely fitted and larger internal memory.


This latest Rapid Response Report (RRR) has been produced following 167 patient safety incidents, between 1 January 2005 and 30 June 2010 and includes eight fatalities.

Ambulatory syringe drivers are often used to deliver opioids and other palliative care medication, over-infusion**, where medicines run through too quickly, can cause death through respiratory depression while under-infusion, where medicine doesn’t infuse at all, can cause pain and distress.


The RRR asks NHS organisations to ensure:


  • they develop a purchasing for safety initiative*** that considers the following safety features before ambulatory syringe drivers are purchased:

a) rate settings in ml per hour;

b) mechanisms to stop infusion if the syringe is not properly and securely fitted;

c) alarms that activate if the syringe is removed before the infusion is stopped;

  • they take steps to reduce the risks of rate errors while older designs of ambulatory syringe drivers remain in use, based on a locally developed risk reduction plan which may include: raising awareness, providing information to support users with rate setting, and using lock-boxes;

  • they set an end date to complete the transition between existing ambulatory syringe drivers and ambulatory syringe drivers with additional safety features (as soon as locally feasible, but before 31 December 2015).

NHS organisations are also asked to take steps to reduce the risks during any transition period when both types of design are in use.


Professor David Cousins, Head of Patient Safety, Medication Practice and Medical Devices, at the NPSA, said: “Effective design of medical devices helps minimise the risk of patient safety incidents in practice. We are recommending that NHS organisations should introduce a purchasing for safety initiative that considers safety features of ambulatory syringe drivers used locally.”


For a copy of this latest RRR, please visit http://www.nrls.npsa.nhs.uk/resources/type/alerts



Notes to editors


1. Media enquiries to the NPSA Press Office:


020 7927 9362 / press.office@npsa.nhs.uk


Out of hours – 0788 411 5956


2. Following the publication of the Arms Length Body Review on 26 July 2010, the NPSA has stressed the importance for all NHS organisations across England and Wales to continue reporting patient safety incidents through the National Reporting and Learning System. This is so that trends in safety incidents can be identified and acted upon as early as possible.  This aspect of our work will continue within the new proposed structure of the NHS Commissioning Board and we will continue to work together in partnership with NHS organisations to make services even safer for patients.  We will continue to monitor the implementation of all patient safety alerts and guidance.


3. *An Ambulatory Syringe Driver is a syringe driver that is portable and suitable for taking out of a hospital.


4. ** The process of continuous injection of a medicine into a patient.


5. ***A purchasing for safety initiative refers to a procurement system, process or policy that advocates and encourages patient safety.