Subject:Alaris/Care Fusion Syringe Pumps. Dear Colleagues,

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1 From: Hupp, Diane Sent: Friday, April 17, :51 PM To: Davis, Peter (ANES); Cain, James G; Ambrose, Heather; Bojtos, Brooke; Brytus, Jeanne M; Butler, Gabriella; Cales, Rebecca; Cancilla, Diane; Carlson, Michele; Carnevali, Mary; Chaplik, Annette; Cooper, Heather-Dawn; Cote, Stacey; DeGeorge, Pamela; Dickman, Jennifer; DiLucente, Michele; Disilvio, Stefanie; Eicker, Paula; Guthrie, Charles E; Hackett, Pam; Hahner, Sheila A; Hupp, Diane; Iagnemma, Jennifer; Kaminski, Marnie; Kennedy, Michaele; Kuch, Bradley A; Lamouree, Margaret; Landgraf, Bonnie; Lesniak, Deborah; Lipinski, Kimberly D; Mcintyre, Melissa J; McLane, Natalie; Mcsteen, Michael; Park, Sue; Petrill, Amanda; Prosser, Debbie L.; Rausch, David; Ricci, Frank G; Schenkel, Kathleen; Schrag, Holly; Spence, Ann; Stanley, Paula B; Straka, Kristen; Terzis, Ann; Tharp, Marcie M; Thomas, Dawn (CHP); Valenta, Cynthia; Vincett, Carrie; Vincze, Durae L; VonHofen, Geraldine; Waltenbaugh, Hope; Wible, Susan R; Wilson, Melissa; Wilson, Sarah; Woodring, Jennifer L; Zwier, Katherine Subject:Alaris/Care Fusion Syringe Pumps Dear Colleagues, As many of you may know, Care Fusion has been on site for the last week performing observations in our PICU as it relates to transitioning syringes on the Alaris Syringe pumps. There has been a noted significant delay while administering select medications with these pumps during the transition of syringes/line changes. The delays are at times causing impact on the patient s hemodynamic stability in the pediatric critical care population. Therefore, at this time, we are immediately removing the Alaris syringe pumps from the critical care units. We are beginning with PICU tonight. CICU is anticipated to transition on Monday followed by NICU. We will also address the OR and any other department such as the ED or if an acute care unit uses the syringe pump for critical care type drips ( this needs evaluated - we have not heard issues from acute care but will verify). Medfusion pumps are being deployed tonight to the PICU. Additional Medfusion pumps are being rented and brought in next week. The drug library will be downloaded prior to being deployed from materials management. Please note that all nurses and other care providers that will use the Medfusion pump must be signed off on competency prior to using the pump even if they have prior experience with the pump. This is a safety feature of implementing pumps and we can take no shortcuts. Heather Ambrose is coordinating the training with her educators and superusers in PICU. Please let me know if you have any questions. Thank you, Diane Diane S. Hupp, DNP, RN, NEA-BC Vice President Patient Care Services & Chief Nursing Officer Children s Hospital of Pittsburgh of UPMC 4401 Penn Avenue Pittsburgh, PA Phone: Fax:

2 This may contain confidential information of the sending organization. Any unauthorized or improper disclosure, copying, distribution, or use of the contents of this and attached document(s) is prohibited. The information contained in this and attached document(s) is intended only for the personal and confidential use of the recipient(s) named above. If you have received this communication in error, please notify the sender immediately by and delete the original and attached document(s).

3 From: Sent: Thursday, April 23, :19 PM To: Hupp, Diane Cc: Subject: RE: Communication/Follow up Hi Diane, I have attached a draft copy of our information notice and tip sheet for your review. As indicated before, we appreciate any feedback you may have and your review will not be considered an endorsement of the contents. Since this is still in draft form, we would appreciate you not distributing so that we will have an opportunity to finalize and send to our customers directly. Best regards and thank you again, Chuck Chuck Donlon Vice President, Quality and Regulatory Affairs Infusion Systems CareFusion Pacific Mesa Blvd. San Diego, CA (858) CareFusion has joined BD Learn more about BD From: Hupp, Diane Sent: Wednesday, April 22, :34 PM To: Donlon, Chuck Cc: Graziano, Cheryl Subject: RE: Communication/Follow up Hi Chuck, Thank you for your reply. Yes, please forward the notification and I will provide my input and suggestions. Thanks, Diane Diane S. Hupp, DNP, RN, NEA-BC

4 Vice President Patient Care Services & Chief Nursing Officer Children s Hospital of Pittsburgh of UPMC 4401 Penn Avenue Pittsburgh, PA Phone: Fax: This may contain confidential information of the sending organization. Any unauthorized or improper disclosure, copying, distribution, or use of the contents of this and attached document(s) is prohibited. The information contained in this and attached document(s) is intended only for the personal and confidential use of the recipient(s) named above. If you have received this communication in error, please notify the sender immediately by and delete the original and attached document(s) From: Sent: Tuesday, April 21, :16 PM To: Hupp, Diane Cc: Subject: RE: Communication/Follow up Dear Diane, As a follow up to our call last Friday, I want to let you know we are following through on our commitment. I have taken the lead for CareFusion in ensuring this happens quickly. We have drafted the notification and are processing approvals through our quality management system. As we discussed, we would appreciate your input on the draft but fully understand if you decide not to. Your review would not be considered an endorsement of the contents and would not be referenced. Our goal would be to get your feedback in order to make the communication as effective as possible. I will forward the draft communication to you for your review, with your approval. We expect that we can finalize the notification by end of week. We will then overnight mail the information to all of our syringe customers. I sincerely hope that your transition to the alternate syringe pumps has been successful. Please contact me with any questions. Best Regards, Chuck Chuck Donlon Vice President, Quality and Regulatory Affairs Infusion Systems CareFusion Pacific Mesa Blvd. San Diego, CA 92121

5 (858) CareFusion has joined BD Learn more about BD From: Graziano, Cheryl Sent: Tuesday, April 21, :07 PM To: Hupp, Diane Cc: Donlon, Chuck Subject: RE: Communication/Follow up Diane, I have forwarded your to Chuck Donlon for his direct reply. As our Vice President for Quality, Chuck is leading our customer communication effort and can provide you a status update. Kind regards, Cheryl From: Hupp, Diane Sent: 4/21/15, 5:32 PM To: Graziano, Cheryl Subject: Communication/Follow up Hi Cheryl, In follow up to our discussion last Friday and as we agreed, has Care Fusion communicated with the Children s Hospitals that have the Alaris syringe pumps to notify them of the significant issues your team has observed here in Pgh and potential harm? Thanks, Diane Diane S. Hupp, DNP, RN, NEA-BC Vice President Patient Care Services & Chief Nursing Officer Children s Hospital of Pittsburgh of UPMC 4401 Penn Avenue Pittsburgh, PA Phone: Fax:

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