ALARIS INFUSION PUMP

Description of Event or Problem

PATIENT HAD SEVERAL IV INFUSIONS RUNNING INCLUDING CALCIUM, POTASSIUM, MAGNESIUM, AND NORMAL SALINE. WHEN NURSE ROUNDED ON PATIENT, SHE NOTICED THAT THE MAGNESIUM BAG WAS EMPTY BUT WAS NOT ALARMING TO STOP THE INFUSION. SHE GLANCED AT THE TUBING AND NOTICED THAT THE TUBING ATTACHED TO THE MAGNESIUM DRIP WAS DRY, EXCEPT SEVERAL INCHES OF TUBING THAT WAS CONNECTED TO THE PATIENT. SHE IMMEDIATELY STOPPED THE INFUSION CHANNEL. NO AIR REACHED THE PATIENT AS THERE WERE OTHER INFUSIONS RUNNING AT THE SAME TIME THAT WERE NOT DRY. THE CONCERN IS THAT THE CHANNEL THAT WAS INFUSING THE MAGNESIUM DID NOT ALARM, BUT CONTINUED INFUSING AS AIR WAS IN THE LINE PAST THE POINT AT WHICH THE PUMP SHOULD HAVE RECOGNIZED AIR. THE NURSE NOTIFIED THE NURSE MANAGER, AND THEY CONTACTED BIOMEDICAL ENGINEERING TO ASSESS DEVICE.