Re: Old-style Graseby syringe drivers (e.g. MS16, MS16A,
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
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
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are found to be in use they should be withdrawn as soon as possible; ensuring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.
MBE, SFFMLM, MChir,
Interim National Director of Patient Safety