EVALUATION FORM

IV pump

DEVICE INFORMATION

Name :

Company : Cardinal Health

Hospira
Smith Medical

ASSESOR INFORMATION

Name :
Department :
Number of days using the device :

Questionnaire: IV pump 1/3

Please complete this questionnaire without conferring with colleagues. The results should represent your own opinion.
For each question, circle the number corresponding to the most suitable answer.

I Appropriateness of Device
Non
Very good Good Adequate Inadequate Poor
applicable

1. The device’s suitability for your application is: 5 4 3 2 1 N/A

2. The battery life is: 5 4 3 2 1 N/A

3. The size of the pump is: 5 4 3 2 1 N/A

4. The weight of the pump is: 5 4 3 2 1 N/A

5. The durability of the pump is: 5 4 3 2 1 N/A

6. The pole clamp is: 5 4 3 2 1 N/A

7. The ease of attaching and detaching module

5 4 3 2 1 N/A
to/from the PC unit (for Cardinal Health only):

II Administration set
Non
Very good Good Adequate Inadequate Poor
applicable

1. The suitability of the supplied administration

5 4 3 2 1 N/A
set is:

2. There are appropriate tubing accessories for all

5 4 3 2 1 N/A
treatment needs:

3. Access ports are easy to clear of air or blood: 5 4 3 2 1 N/A

4. Blood administration set is: 5 4 3 2 1 N/A

III Loading the set

Non
Very good Good Adequate Inadequate Poor
applicable

1. The loading procedure for the set/syringe is: 5 4 3 2 1 N/A

2. The priming procedure for the set/syringe is: 5 4 3 2 1 N/A

3. The ease of setting syringe brand and size is:
5 4 3 2 1 N/A
(for syringe pump only)

IV Setting parameters and starting infusion

Non
Very good Good Adequate Inadequate Poor
applicable

1. The ease of setting parameters is: 5 4 3 2 1 N/A

2. The ease of navigate the control panel is: 5 4 3 2 1 N/A

3. The visual displays are: 5 4 3 2 1 N/A

4. The clarity of messages are: 5 4 3 2 1 N/A

V Dose Error Reduction System DERS

Non
Very good Good Adequate Inadequate Poor
applicable

1. The ease to activate DERS features is: 5 4 3 2 1 N/A

2. The ease to enter drug/fluid from the library is: 5 4 3 2 1 N/A

3. The clarity of out-of-limit messages are: 5 4 3 2 1 N/A

Questionnaire: IV pump 2/3

4. The clarity of clinical advisory messages are: 5 4 3 2 1 N/A

5. Drug high/low limits are appropriate: 5 4 3 2 1 N/A

VI Monitoring the infusion

Non
Very good Good Adequate Inadequate Poor
applicable

1. The noise level whilst running is: 5 4 3 2 1 N/A

2. The running indicator clarity is: 5 4 3 2 1 N/A

3. The display of rate/VTBI during an infusion is: 5 4 3 2 1 N/A

4. The alarm messages are: 5 4 3 2 1 N/A

5. The alarm tone is: 5 4 3 2 1 N/A

6. The appropriateness of alarms are: 5 4 3 2 1 N/A

7. The safeguards against tampering are: 5 4 3 2 1 N/A

8. In-line resistance gauge was appropriate: 5 4 3 2 1 N/A

VII Infusion complete

Non
Very good Good Adequate Inadequate Poor
applicable

1. The ease of clean is: 5 4 3 2 1 N/A

2. The ease of charging is: 5 4 3 2 1 N/A

3. The clarity of event memory is: 5 4 3 2 1 N/A

VIII Manufacturer support

Non
Very good Good Adequate Inadequate Poor
applicable

1. Rep was available to assist/answer any clinical

5 4 3 2 1 N/A
applications/questions:

VIII Overall Satisfaction

Non
Very good Good Adequate Inadequate Poor
applicable

1. This pump is: 5 4 3 2 1 N/A

IX Comment
Please use the back of this sheet to add any additional comments that you would like to make on your experience of using this pump

Questionnaire: IV pump 3/3