Intravenous news: The NPSA report on the issue of ambulatory syringe drivers. “Ambulatory syringe drivers are widely used in palliative care and for long term care in the community and in hospital. As a result they are often used to deliver opioids and other palliative care medication. Over-infusion of these medications can cause death through respiratory depression, while under-infusion can leave the patient in pain and distress.
While the majority of syringe drivers and pumps used in healthcare have rate settings in millilitres (ml), some older types of ambulatory syringe drivers have rate settings in millimetres (mm) of syringe plunger travel. This is not intuitive for many users and not easy to check. Errors include the wrong rate of infusion caused by inaccurate measurement of fluid length or miscalculation or incorrect rate setting of the device. Dose errors also occur because of different models using mm per hour or mm per 24 hours. Other issues include syringes becoming dislodged, inadequate device alarms and lack of internal memory (a technical issue which makes establishing the reason for any over or under-infusion difficult).”