BD ALARIS PUMP

Description of Event or Problem

PATIENT IS AN 85-YEAR-OLD FEMALE WITH A HISTORY OF ADVANCED CHRONIC LYMPHOCYTIC LEUKEMIA WITH PROGRESSIVE MARROW FAILURE, CHRONIC KIDNEY DISEASE STAGE 3, HEART FAILURE WITH MILDLY REDUCED EJECTION FRACTION, AND CORONARY ARTERY DISEASE, WHO WAS ADMITTED ON (B)(6) 2026 FOR ACUTE RESPIRATORY FAILURE WITH HYPOXIA AND CHEST PAIN. PULMONARY AND CRITICAL CARE CONSULTANTS DETERMINED THE ETIOLOGY WAS MOST CONSISTENT WITH ACUTE CARDIOGENIC PULMONARY EDEMA, WITH INFECTION CONSIDERED LESS LIKELY GIVEN AFEBRILE STATUS AND NEGATIVE PROCALCITONIN. SHE RECEIVED A TRIAL OF NONINVASIVE VENTILATION AND DIURESIS. DURING THE HOSPITALIZATION, SHE DEVELOPED HEMODYNAMIC INSTABILITY REQUIRING VASOPRESSOR SUPPORT. SHE EXPERIENCED RECURRENT EPISODES OF CHEST PAIN WITH RISING TROPONIN (24 TO 2558). CARDIOLOGY WAS CONSULTED GIVEN CONCERN FOR ACUTE CORONARY SYNDROME. SHE DEVELOPED ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE, MANAGED WITH AMIODARONE AND HEPARIN DRIP. HEPARIN DRIP 25,000 UNITS/500ML (50 UNITS/ML) INFUSION WAS ORDERED FOR 750 UNITS/HR. USING THE BD ALARIS PUMP, RN ENTERED "750" IN THE RATE (ML/HR) FIELD, INSTEAD OF THE DOSE (UNIT/HR) FIELD. THIS WOULD HAVE RESULTED IN 37,500 UNITS/HR. A WARNING OF DOSE GREATER THAN 3000 UNITS/HR WAS OVERRIDDEN. PATIENT RECEIVED ~10,625 UNITS OF HEPARIN IV IN 17 MINUTES BEFORE ERROR WAS CAUGHT. PER INTENSIVIST, THE FINAL OUTCOME IS NOT CAUSED BY THE EVENT AND UNLIKELY CONTRIBUTED BY THE EVENT (THERE WAS NO MASSIVE BLEEDING EVENT PRIOR TO PASSING). HER COURSE WAS COMPLICATED BY PROGRESSIVE MULTI-ORGAN DYSFUNCTION, INCLUDING WORSENING RESPIRATORY FAILURE, SHOCK, AND CARDIAC ARRHYTHMIAS. PATIENT WAS PRONOUNCED DEAD ON (B)(6) 2026. ADDENDUM: A FORMAL COMPLAINT WAS ALREADY FILED WITH BD WITH REGARDS TO THE DESIGN OF THE ALARIS PUMP. WHEN THE DRUG LIBRARY IS BEING USED WITH A CERTAIN UNIT (IN THIS CASE HEPARIN WITH "UNITS/HR"), THE RATE FIELD OF ML/HR WHICH LOCATED ON THE TOP OF THE SCREEN SHOULD NOT BE PROGRAMMABLE. THIS HAS BEEN A SAFETY CONCERN FOR YEARS. DURING THE LAST/MOST RECENT BD ALARIS PUMP RECALL WHERE NEW PUMP DESIGN WAS REQUIRED, IT'S A BIT DISAPPOINTING THAT THE RATE FIELD IS NOT LOCKED OUT OR REMOVED WHEN THE DRUG LIBRARY IS USED.