ECRI has named Vancouver Coastal Health and Lower Mainland Biomedical Engineering as winners of its 14th Health Devices Achievement Award. Through a joint collaboration, the Canadian healthcare organizations successfully uncovered the cause of potentially fatal medication over-infusions. Their investigation led to a global recall of hundreds of millions of defective infusion pump tubing sets.
“Vancouver Coastal Health and Lower Mainland Biomedical Engineering are to be congratulated for the impact they have had in improving patient safety. Their investigation has certainly saved many lives,” says Marcus Schabacker, MD, PhD, ECRI’s president and CEO.
Vancouver Coastal Health and Lower Mainland Biomedical Engineering began its infusion pump investigation in July 2018 after a patient received what had the potential to be fatal intravenous (IV) infusion of morphine in minutes, rather than over several hours. Upon further review, the Canadian team uncovered more than 30 over-infusion events throughout British Columbia health facilities involving this same model of pump. New evidence in March 2019 led investigators to identify that defective tubing was a contributing factor towards the uncontrolled flow.
“What started as an effort to solve a problem within the Canadian health system ultimately helped improve patient safety throughout the world,” says Brendan Gribbons, PEng, MEng, CCE, regional engineering team manager, Lower Mainland Biomedical Engineering. “It’s an honor for Vancouver Coastal Health and Lower Mainland Biomedical Engineering staff to be recognized by ECRI for the team’s persistence and great investigative work.”
“The outcomes achieved were only possible as a result of the exceptional teamwork and resilience as well as the shared commitment to patient safety that extended across the entire health care team,” adds Brittany Watson, RN, MSN, director of professional practice at Vancouver Coastal Health. “From the nurses and physicians to clinical leaders, to biomedical engineers and quality and practice leaders, every team member played an essential role in successfully identifying the root cause of this problem.”
The investigation led to several corrective courses of action. The pump manufacturer examined its inventory and quality control systems and worked with suppliers to identify the cause of the tubing abnormality. The company initially identified and recalled 75 lots that potentially contained the abnormal tubing that were sent to British Columbia. In the summer of 2019, the recall expanded globally to include more than 150 million tubing sets recalled in the United States alone. The dimensional defect quite possibly explains years of unexplained over-deliveries of medications with this particular system.
“Infusion errors, which are a frequent source of patient harm, can take many forms and have many causes,” notes David Jamison, executive director of selection and evaluation at ECRI. “Evidence-driven investigations that identify root causes and improve patient safety are the kind of initiative we are proud to recognize with our award.”
ECRI also named two finalists for this year’s award:
- Memorial Healthcare System (Miramar, Fla.) | Reducing Weight-Based Medication Errors
- NewYork-Presbyterian Queens (Flushing, N.Y.) | Transforming Pharmacy Compounding Practice
ECRI’s Health Devices Achievement Award is given each year to a member healthcare facility for undertaking an initiative to improve patient safety, reduce costs, or otherwise facilitate strategic management of health technology.