Sign In
CPSI Share                                                                  
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Back to Search
Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 11/5/2019 12:00:00 AM
Country: United Kingdom
Organization: NHS Commissioning Board
This alert discusses the patient safety incidents which may occur when a device used to access the blood supply through the intraosseous route is not working due to a depleted battery charge. The intraosseous (IO) route (that is, through the bone marrow) is used to access the venous system when intravenous access is not possible, often in emergency situations, including cardiopulmonary resuscitation. IO access is most commonly achieved using a battery-powered injector. As the battery is sealed within the device and cannot be recharged or replaced, the first sign a battery may be depleted is in some circumstances when it does not work. This alert asks providers to replace any battery-powered IO devices that do not have a battery power indicator light with ones with a display that shows how much power is remaining. Where IO devices with a battery power indicator are used, providers are asked to take steps to embed regular checks of these devices to ensure sufficient battery power remains so the devices are always ready and available. Specific actions are provided in the alert.

Additional Details

Device:
battery powered intraosseous injector

Environment / Equipment
  1. Identify and replace any battery-powered IO injectors without a battery indicator light.
  2. For battery-powered IO injectors with a battery indicator light, ensure resuscitation equipment checklist (and ‘make ready’ equipment checks and replenishment in ambulance trusts) includes: a. how to check the device, and where to record that the indicator light shows the battery is working i.e. green LED b. a prompt that a flashing red LED means the IO injector must be replaced, and how to obtain a replacement
Training
  1. Review training materials A and competency frameworks and ensure they include how to avoid the injector stalling mid-use and what to do if this occurs.

Depleted batteries in intraosseous injectors