Infusion Pump Remediation in Lower Mainland B.C. Health Authorities

Abstract

Infusion pumps deliver fluids and medications at controlled flow or dose rates into a patient’s body. All health authorities within the Lower Mainland (LM), British Columbia are standardized to use Becton Dickinson (BD) Alaris Infusion pumps.

In 2020, BD initiated four voluntary recalls to address several software and hardware issues with the Alaris infusion system [1]-[4], all which have the potential to result in severe patient harm or death. In 2021, the required software and hardware fixes to mitigate these risks were approved by Health Canada. All device components of the Alaris infusion system require remediation, including PCU “Brains” and pumping modules. Every devices will be temporarily removed from clinical service to be upgraded by BD.

Within the LM, over 18,000 devices required remediation across 62 facilities, including 27 acute hospitals. Remediated devices are not backwards compatible with non-remediated devices (e.g., if nurse connects a remediated PCU with a non-remediated module an error occurs). Given the scope and incompatibility constraint, Lower Mainland Biomedical Engineering (LMBME) required a coordinated and planned approach to remediate all pumps.