Notification of investigation

HSIB have launched an investigation after being notified of three incidents where an accidental fentanyl overdose occurred. The Trust had administered the powerful pain medication using a ‘smart’ infusion device.

‘Smart’ infusion devices (or smart pumps) are used when administering intravenous medication (drugs that go directly into a vein). They have built-in ‘dose error reduction’ software that aims to reduce the likelihood of patient harm if the device is setup incorrectly.

Initial research carried out by the HSIB investigation team suggests that it may be challenging to integrate or replace current systems used to administer intravenous medication in NHS trusts.

The investigation will examine the current procurement, usability and adoption of the smart pumps, and look at what might be needed to introduce smart pumps effectively in trusts across England.

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