Authors (including presenting author) :
Leung TM (1), Ho YH(1), Leung PN(1), Tai CW(2), Choi LY(2)
Affiliation :
(1) Cluster Quality and Safety Office, Hong Kong East Cluster, (2) Cluster Biomedical Engineering Services, Hong Kong East Cluster
Introduction :
The Agilia infusion pump from Fresenius Kabi is widely used in HKEC, accounting for approximately 82% of all infusion pumps. An incident in March 2024 involving the Agilia infusion pump highlighted issues with the Keep Vein Open (KVO) mode, which produced a soft, intermittent alarm that was often overlooked by users. This resulted in medication being infused at an unintended rate of 1 ml per hour for 23 minutes. Additionally, discrepancies in alarm settings across departments were observed. To enhance patient safety, the Cluster Quality and Safety Office (CQ&SO) in HKEC initiated a program to align the alarm settings with safe standards.
Objectives :
To standardize alarm settings for Agilia infusion pumps in HKEC and ensure that users understand these measures, thereby facilitating the safe administration of medication using the Agilia infusion pumps.
Methodology :
Coordination was established with the Cluster Biomedical Engineering Services (CBME), the Agilia infusion pump vendor, and departmental users to reach a consensus on aligning alarm settings. CBME and the vendor provided expert input on the parameters for these settings. The aligned alarm configurations included disabling the KVO function to activate a prominent alarm at the end of infusion, activating the near-end infusion alarm a few minutes before the end of infusion, and setting initial pressure limits that would trigger an alarm in the event of occlusion.
The implementation of the alarm settings for the Agilia infusion pumps in HKEC was carried out by the vendor and monitored by CBME and CQ&SO. After alarm setting of each infusion pumps, labels indicating the alarm settings were affixed to the infusion pumps to remind users of the configurations. Demonstration sessions were conducted for the involved departmental users in HKEC to explain the importance of these adjustments, and an educational video on alarm settings was made accessible on the intranet. Additionally, departmental users were encouraged to report any adverse effects following the improvement program.
Result & Outcome :
Departmental users acknowledged the importance of the aligned alarm settings. All Agilia infusion pumps in HKEC have had their alarm settings aligned and labeled, while the relabeling of syringe pumps to provide concise and prominent information is ongoing. No incidents related to Agilia infusion pumps have been reported following these implementations, and no adverse effects were noted after the improvement program.
