LIFESHIELD PRIMARY SYMBIQ SET PIGGYBACK WITH BACK CHECK VALV
Received Jun 13, 2014 · Event occurred Jun 12, 2014
Report 3893491 · MDR key 3893491
Device
Generic name
Tubing, Fluid Delivery
Manufacturer
Hospira, Inc.Model number
*Catalog number
16120-28
Lot number
*
Product problems
- Improper Flow or Infusion
- Infusion or Flow Problem
Patient
*
- No Consequences Or Impact To Patient
Narrative
Description of Event or Problem
THE MAIN IV D5.45NS/20 KCL WAS INFUSING THROUGH THE CENTRAL LINE ON A CABG (CORONARY ARTERY BYPASS GRAFT) PATIENT. RN HUNG A 1 GRAM CALCIUM CHLORIDE 60 CC RIDER AS A SECONDARY INFUSION TO THE MAIN IV. A FEW MINUTES LATER WHEN THE RN LOOKED UP HE REALIZED THAT THE CALCIUM RIDER HAD BOLUSED INTO THE PRIMARY INFUSION BAG. THE SECONDARY BAG HAD BYPASSED THE PUMP COMPLETELY. IT APPEARS THAT THE ANTI-REFLUX VALVE WITHIN THE PRIMARY TUBING HAD FAILED. THE RN HAD A 2ND RN CHECK AND THEY BOTH AGREED THAT THE IV PUMP AND TUBING HAD BEEN PROPERLY CONNECTED AND THE PUMP WAS SET-UP CORRECTLY. NO APPARENT HARM. PATIENT MONITORED.