- Different models of Graseby syringe drivers are in use in other Trusts including the Graseby MS16a Hourly rate syringe driver. The MS16a (blue front facing) and MS26 (green front facing) are very similar.
- • The most common syringe drivers in clinical use are the SIMS Graseby® MS16A and the MS26 3-5; • The organisation’s protocol regarding the preparation and set-up.
- Use of the Graseby MS26 Syringe Driver For Palliative Care Within West Lothian. Different models of Graseby syringe drivers are in use in other Trusts including the Graseby MS16a Hourly rate syringe driver. The MS16a (blue front facing) and MS26 (green front facing) are very similar. Graseby syringe drivers are calibrated in mm.
A whistle-blower has claimed the Gosport inquiry ignored concerns that some syringes could be misused to administer dangerously high doses of medicine.
The claims asserted that the concerns were ignored in order to avoid a national scandal and that the NHS was slow to take certain syringes out of use.
The result may have been thousands more deaths.
Graseby Syringe Pump Manual
Explaining the issue, Dr Iain Lawrie, vice president of the Association for Palliative Medicine, told Sky News that some hospitals used two types of syringes in one unit - one to deliver drugs once an hour and the other to deliver drugs once every 24 hours.
Both the Graseby™ 2000 and the Graseby™ 2100 syringe pumps provide simple, reliable and easy to use infusions for a range of clinical therapy areas. Both pumps deliver medication as a continuous infusion at rate between 0.1ml/h to 1200ml/h depending on the syringe size.
'In trained hands, syringe drivers always have been safe, with good prescribing. But it's in untrained hands and people who have been prescribing doses that possibly they shouldn't... that's where the issues lie.'
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According to The Sunday Times, the whistle-blower was on the inquirywhich concluded 456 people had their lives shortened after they were prescribed powerful opioids without medical justification.
The panel was warned a national helpline would have to be set up, as well as a compensation fund, if the full scale of the scandal emerged.
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Health Secretary Jeremy Hunt has rejected the allegations - and insisted the independent inquiry 'would have said' if there had been an issue.
'We have to respect the fact that this was an independent panel led by Bishop James Jones... this is someone who has spent his life taking on the British establishment,' he said.
However, Mr Hunt added the government would look into all the evidence relating to the use of the syringes, which were banned in countries such as New Zealand and Australia.
He said: 'We need to look at all the evidence that we have... Urgent advice was sent as far back as 2010 and the information I have is that they were taken out of use in 2015... We will look at if that was as quick as it should have been.'
The whistle-blower had told the newspaper: 'Anyone who has lost their granny over the past 30 years when opiates were administered by this equipment will be asking themselves, 'Is that what killed Granny?'
The Graseby MS26 and Graseby MS16A syringe drivers were open to misuse, the claims say.
About 40,000 of the devices - a quarter of the worldwide total - were in the UK, the majority in primary care.
A 2008 paper by the NHS's now-defunct Purchasing and Supply Agency (PSA) said the devices were an 'essential component of palliative care'.
The PSA said the devices, which appeared 'very similar aside from colour', delivered drugs at different rates.
'Confusing MS16A (which delivers in mm per hour) with MS26 (which delivers in mm per 24 hours) can result in an infusion rate 24 times higher than required, and numerous adverse incidents of their type have been reported,' the PSA said.
It added there were safer alternatives.
The Gosport report said: 'The panel has considered issues concerned with the particular syringe drivers, known by their trade name of Graseby, and is aware of the hazard notices which applied.
'The panel's analysis does not rest upon any issue relating to these notices.'
A Department of Health and Social Care spokesman said: 'While there is a range of statutory requirements to monitor and improve safe management and use of controlled drugs, we would not hesitate to take further action to improve safety.'
Hp Drivers For Mac
The panel said: 'These allegations are completely unfounded and without merit or support.'
We are sending the below letter on behalf of interim National Director of Patient Safety at NHS Improvement, Celia Ingham-Clark, who has sent a similar letter to all NHS trusts following the release of the Gosport Independent Panel Inquiry on 19 June 2018. The report highlighted concerns about the ongoing availability and usage of certain models of Graseby syringe drivers, specifically the use of the older Graseby syringe drivers that worked by measuring millimetres of syringe length (e.g. MS16, MS16A, MS26). Please contact NHS Improvement directly with any queries.
Ms16a Manual
Patient Safety NHS Improvement Wellington House 133-155 Waterloo Road London SE1 8UG
26 June 2018
Dear colleague,
Re: Old-style Graseby syringe drivers (e.g. MS16, MS16A, MS26)
You will be aware of the media interest over the weekend in relation to the Gosport Inquiry and specifically the use of the older Graseby syringe drivers that worked by measuring millimetres of syringe length (e.g. MS16, MS16A, MS26).
A National Patient Safety Agency (NPSA) ‘Rapid Response Report’ was issued in December 2010 requiring organisations to ‘agree an end date to complete the transition between existing ambulatory syringe drivers and ambulatory syringe drivers with additional safety features (as soon as locally feasible, and within five years of this RRR)’. This advice was given not because the Graseby syringe drivers had any mechanical faults, but because the complexities of converting doses to mm of syringe length, and confusion between models that had ‘per 24 hours’ settings and models that had ‘per hour’ settings, had continued to lead to error. By the time of the NPSA RRR, alternative models of syringe driver with enhanced safety features had become available.
The NPSA requirement applied to all providers of NHS funded care in England, including in the independent sector and third sector. Hospices should therefore have acted on the alert at the time. Whilst the NPSA’s remit did not extend to providers who only ever care for privately funded patients, we know that these providers, and the healthcare professionals who work within them, also aim to implement any relevant safety advice.
We are therefore not envisioning any of these older style syringe drivers to still be in use.
However, we would urge you to undertake local checks to ensure that none of the old-style Graseby ambulatory syringe drivers, that worked by measuring millimetres of syringe length, are still in use in your organisation (e.g. MS16, MS16A, MS26).
We are aware that large chains may hold medical device asset registers which should provide the necessary information but we know that often these syringe drivers may have been purchased directly by clinical teams using charitable donations and may not have gone through formal organisational purchasing routes. We would therefore encourage organisations to directly contact all their clinical teams and units to check if they have any old-style syringe drivers.
We would advise that if any of these types of syringe drivers are found to be in use they should be withdrawn as soon as possible; ensuring patient care is not compromised.
Thank you for undertaking this additional check to ensure past safety advice has been fully implemented.
Yours sincerely,
Celia Ingham-Clark MBE, SFFMLM, MChir, FRCS, FRCA Interim National Director of Patient Safety NHS Improvement