A smart infusion pump at a patient's bedside.

Procurement, usability and adoption of ‘smart’ infusion pumps

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Investigation summary

Infusion pumps are medical devices that are used when administering medication to patients. The latest generation of infusion pumps, commonly referred to as ‘smart’ pumps, are being used in many healthcare settings. The smart functionality aims to prevent overdoses or underdoses that could result in serious patient harm or death.

Although the aim of smart infusion pumps is to improve patient safety, the technology can introduce new risks. This investigation report focused on understanding the challenges involved in introducing smart infusion pump technology within NHS hospitals.

We launched an investigation after being notified by an NHS Trust about three patient safety incidents. The three incidents, all involving fentanyl (a powerful pain medication), occurred in three different critical care units. They were linked by the Trust to the introduction of the smart technology.

The investigation used these incidents to examine the emerging risks relating to the implementation of smart pumps.

The investigation found that the implementation of smart pump functionality would benefit from the use of risk management practices, as requirements are complex and similar to the introduction of a new IT system. Existing NHS Clinical risk standards could provide a basis for both manufacturers and trusts to work together to manage risks.

The investigation highlighted the main implementation challenges. This includes:

  • National consistency in drug libraries – smart infusion pumps have an inbuilt dose error reduction system (DERS) which requires the use of a drug library. The investigation found that drug libraries were developed ‘locally’ and that there is no agreed national drug library for use in NHS. They also found that there is no national guidelines or standards on how to implement the libraries.
  • Significant changes in processes – introducing the technology requires significant changes to prescribing and administration processes in trusts. The investigation found that procedure and guidance documents often needed updating, and variations in medication practice were ‘locally managed’ and were rarely shared within and between hospitals.
  • Provision of specialist IT support and infrastructure – substantial IT infrastructure is needed to support the integration of smart pump technology. Software is needed to upload the drug library to smart pumps, download data logs (including any errors detected) and monitor the status of each smart pump. The investigation highlighted that maintaining the required IT infrastructure required specialist staff roles and often a new skill set.
Investigation report