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Pump Issues – Questionnaire
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-
Step
1
of 3
Serial Number (Starts with 207, 208, 303):
Event Date:
Event Time:
Event Description:
Cassette Issues
Did you have any difficulty in closing the cassette door?
Yes
No
Is there anything that inhibits closing the door with the cassette installed?
Yes - supply feedback
No
If yes:
Is there anything (foreign body) preventing the cassette from being dropping into position (such as an IV cap)
Yes - supply feedback
No
If yes:
Is there any obvious fluid spillage in the area where the cassette is loaded? Or is this area dirty?
Yes - supply feedback
No
If yes:
Is there any visible damage or issues with the cassette door/ door latch (such as cracks, out of alignment)
Yes - supply feedback
No
If yes:
Did you receive a specific alarm?
Yes - supply feedback
No
If yes:
Did you try a different tubing set?
Yes
No
Did a different set work with no issues?
Yes
No
If no - supply list/lot of supplementary sets used
Was there a problem with the infusion set?
Yes - supply feedback
No
If yes:
Did you try the set with another pump?
Yes
No
Did the set work with no issues?
Yes
No
What is the list/ lot of the set that was in use?
Next
Battery Issues
Did you receive a specific alarm?
Yes - supply feedback
No
If yes:
Did the charge indicator light up when the device was plugged into an outlet?
Yes
No
Will the pump operate on battery?
Yes
No
Was therapy resumed on a replacement pump?
Yes
No
Physical Damage to Pump
Where was the pump at the time of the event
Was there any physical force impact to the pump? (such as being dropped)
Yes - supply feedback
No
If yes:
Do you see any physical damage to the pump?
Yes - supply feedback
No
If yes:
Next
Further Details
Was a patient involved?
Yes- supply feedback
No
If yes:
Were there any adverse reactions by the patient?
Yes - supply feedback
No
If yes:
Were there any need for medical interventions?
Yes - supply feedback
No
If yes:
Did the pump issue cause a delay in treatment? (treatment had to be ceased)
Yes - supply feedback
No
If yes:
Was anyone harmed as a result of the reported event?
Yes - supply feedback
No
Unknown
If yes:
If yes, who was harmed?
Patient
Healthcare Worker
Other
What was the status of the pump at the time of the event?
Infusing – What were the programmed settings
Upon power on/ self-start
During set-up/ priming
During programming – What were the programmed settings
Other – explain
Please enter programmed settings or explain "other" here:
When did the pump receive its most recent preventative maintenance?
Name
Signature
Clear Signature
Date Completing Questionnaire
Submit
