WALKMED®

Description of Event or Problem

PATIENT DID NOT ACTUALLY RECEIVE MEDICATION DUE TO ADVERSE DRUG EVENT FROM ANOTHER MEDICATION. THIS PATIENT'S FLUOROURACIL (5-FU) BAG WAS MADE AND STORED FOR FUTURE USE. UPON INSPECTION IN STORAGE IT WAS DISCOVERED THAT IT HAD LEAKED. NO PATIENT HARM. PATIENT CAME TO CLINIC FOR 5-FU DISCONNECT AND IVF. WHEN PUMP EXAMINED CRYSTALLIZATION NOTED AROUND PUMP AND ON POUCH. THE 5-FU WAS DISCONNECTED WITH 2 ML REMAINING. NO PATIENT HARM. PHARMACIST REPORTED THAT PATIENT'S FLUOROURACIL INFUSION BAG WAS LEAKING AND HAD TO BE REPLACED. NO PATIENT HARM.