Tooke L J, Howell L
Neonatal Department, Groote Shuur Hospital, Cape Town, South Africa.
Anaesth Intensive Care. 2014 Jul;42(4):467-72. doi: 10.1177/0310057X1404200407.
There have been many reported adverse incidents due to syringe driver use, most of which have been attributable to human error. In this paper we present a previously unreported, but potentially widespread practice which may result in significant over or under-delivery of medication. Even with the naked eye it is evident that syringes of equal volume have different dimensions and to quantify this we sectioned a range of syringes and measured the inner and outer dimensions. Extensive menus for syringe brand and volumes are available on syringe drivers, offering users greater flexibility. However, this feature also allows users to select an incorrect syringe brand with potential consequences for drug delivery. We measured outputs under all selectable permutations, to determine the degree of fluid delivery variation and discovered inaccuracies in volumes ranging from 10% under-delivery to 24% over-delivery. There is a wide variation in syringe metrics and complex syringe menus may increase errors, resulting in significant under or over-delivery of medication. Availability of more than one brand of syringe in a clinical area increases the risk of adverse drug delivery events. Systems need to be implemented to minimise the risk of adverse events.
已有许多因使用注射器驱动泵而报告的不良事件，其中大多数可归因于人为错误。在本文中，我们介绍一种先前未报告但可能广泛存在的做法，这种做法可能导致药物输送显著过量或不足。即使肉眼可见，等体积的注射器尺寸也不同，为了量化这一点，我们对一系列注射器进行了剖切并测量了其内外尺寸。注射器驱动泵上有大量注射器品牌和容量的选项，为用户提供了更大的灵活性。然而，这一特性也允许用户选择错误的注射器品牌，可能会对药物输送产生影响。我们测量了所有可选组合下的输出量，以确定液体输送变化的程度，并发现输送量存在10%的不足到24%的过量等不准确情况。注射器规格存在很大差异，复杂的注射器选项可能会增加错误，导致药物输送显著不足或过量。临床区域有多个品牌的注射器增加了不良药物输送事件的风险。需要实施相关系统以尽量减少不良事件的风险。
