The Betsy Lehman Center’s “Patient Safety Beat” newsletter this month features critical care nurses at Beth Israel Deaconess Medical Center, who, after a software upgrade to the facility’s infusion pumps, noticed a persistent problem with them.

As the story notes, the Baxter Healthcare Corporation’s update increased the sensitivity of the occlusion alarm, which regularly stopped the infusion. “While intended to improve safety, the software update resulted in frequent interruptions for nurses and potential harm to critical care patients in need of continuous drug infusion,” the article noted.

The nursing team recognized the seriousness of the problem, worked with BIDMC’s clinical engineers and Baxter, and that work ultimately led to the U.S. Food and Drug Administration issuing a nationwide recall of the product.

“Being fixated on patient safety and continuing to call out safety issues is just part of this culture,” says Suzanne Joyner, D.N.P., R.N., associate chief nurse for critical care and west campus inpatient service at BIDMC. “A big part of this story is that something that seemed pretty small was called out by multiple people and created this national recall.”

The BIDMC team received a DAISY Team Award, and the FDA awarded BIDMC a Certificate for Outstanding Contribution in Promoting Patient Safety with Medical Devices.