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Coordinated Response to HSIB Recommendations for ‘Smart’ Infusion Pumps

1 November 2022

In early 2021 our procurement, contracting and clinical team began the extensive pre-tender planning for the launch of the Infusion Pumps, Administration Sets and Associated Products National Framework renewal, which launched in October 2022. In February 2021 our Clinical and Product Assurance Team (CaPA) were approached by the Healthcare Safety Investigation Branch (HSIB), who had conducted an investigation into the safe use of ‘Smart’ Infusion Pumps.

As part of the outcomes of this report, HSIB made two recommendations, one to our organisation and one to MEDUSA. The recommendation for us was that ‘NHS Supply Chain develops an agreed specification that defines an open standard format for the sharing of event log data, thus allowing dose error reduction systems (DERS) to be evaluated to establish patient safety benefits.’

See our Useful Links section to view the full HSIB recommendations.

The Challenge

Pre-tender planning was already in flight, so a quick and co-ordinated response was needed. NHS Supply Chain had provided an initial response to the recommendations stating,

NHS Supply Chain is actively engaged in the development of essential specifications as part of the ongoing service development within our Clinical and Product Assurance (CaPA) team. As part of this work all future procurement frameworks will be adopting the essential specification principles, including technical requirements, to ensure products procured are not only value for money, but fit for purpose, safe and represent Health and Care Professionals as well as patient and carer need.

NHS Supply Chain’s CaPA team and the NHS Supply Chain Procurement Clinical Quality Assurance team initiated a conversation with NHS England to ensure the HSIB recommendation could be executed in accordance with HSIB stipulated timelines. Throughout the tendering process, additional meetings also took place to establish how the HSIB recommendations could be incorporated into the NHS Supply Chain essential specification principles, how it applied to the tender and what it meant for NHS Supply Chain suppliers.

The NHS Supply Chain essential specification is a key part of the framework documentation and ensures a minimum set of requirements must be met by all suppliers submitting a response on upcoming tenders.

If you work in Health and Social Care, patient safety should be everyone’s business. We all have a role to play. From front-line care givers, to finance managers, HR partners and procurement specialists, we can all play our part in supporting the patient safety agenda. As a central procurement function supporting the NHS, one of our key purposes and functions to the NHS, is to enable the availability and supply of high quality, innovative, safe and fit-for-purpose products for use in the delivery of safe and effective care. This is a fantastic example of a collaborative coordinated system response to supporting learning from patient safety incidences

Tracey Cammish, Patient Safety and Clinical Intelligence Lead, NHS Supply Chain.

Solution and Benefits

Teamwork, collaboration and a timely response, enabled the HSIB recommendations to be included within the NHS Supply Chain essential specification for Infusion Pumps, and enables trusts to utilise data in a way that supports patient safety. Included in the specification, specifically relating to Smart Pumps following the recommendation was that they must:

  • Utilise technology to assist healthcare providers with programming and calculating dose and delivery rates
  • Must have the ability to export history from the infusion pump to an open standard format for example, infusion pump data downloading, uploading and reporting
  • Training provided by supplier included in spec on-site. Training must be available for end user for the full functionality competency-based user. Training for the full functionality of the product must be included in the cost of the core pump including mechanical functionality, cleaning, and general operation.

Next Steps

The swift response by NHS Supply Chain to the HSIB recommendation supports clinicians in the ability to analyse patient safety data and allows the sharing of data through open access.

See our Useful Links section for more information on the recently launched Infusion Pumps, Administration Sets and Associated Products Framework.

For further information on this framework please contact our Hospital Care Team.