BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ALARIS PRIMARY TUBING SET 20 DROP

    MDR report key: 1202337 · Received October 15, 2008

    Report

    Report Number
    MW5008644
    Event Type
    Malfunction
    Date Received
    October 15, 2008
    Date of Event
    October 15, 2008
    Report Date
    October 15, 2008
    Manufacturer
    ALARIS
    Product Code
    FPA
    Product Problem
    Yes
    Report Source
    Voluntary report
    Reporter Location
    AZ, US
    Reporter Occupation
    PHARMACIST

    Narratives

    Description of Event or Problem · 1

    THE PATIENT'S RN NOTICED THAT THE ALARIS PUMP WAS CLOGGED, AS IT WAS GIVING AN ALERT. WHEN THE TUBING INSIDE THE ALARIS PUMP WAS INSPECTED, THE RN NOTICED THE TUBING WAS DISCOLORED. THE COLOR OF THE TUBING THAT WAS INSIDE OF THE PUMP IS A LIGHT MAUVE/PINK COLOR. THE TUBING ABOVE AND BELOW IS COLORLESS AND CLEAR. A SYRINGE WAS USED TO ASPIRATE THE FLUID INSIDE OF THE COLORED TUBING. THE FLUID WAS ALSO COLORLESS WITH NO VISIBLE PRECIPITATE, AND THE EMPTY TUBING WAS STILL MAUVE/PINK IN COLOR. WHEN ASKED, THE RN STATED THAT VANCOMYCIN, NORMAL SALINE AND PRIMAXIN COULD HAVE BEEN RAN THROUGH THE SAME TUBING. LOOKING AT MICROMEDEX ONLINE, VANCOMYCIN AND PRIMAXIN ARE COMPATIBLE TOGETHER. MERCK WAS CONTACTED TO INQUIRE IF THEIR PRODUCT, PRIMAXIN, IS COMPATIBLE WITH VANCOMYCIN. THE MERCK WEBSITE LISTS THAT NO OTHER ANTIBIOTICS SHOULD BE MIXED WITH PRIMAXIN. THE MERCK EMPLOYEE STATED THAT IT WOULD TAKE UP TO TWO WEEKS FOR THIS INFORMATION ON COMPATIBILITY TO BE FAXED TO OUR FACILITY. I LOOKED UP BOTH VANCOMYCIN AND PRIMAXIN IN MOSBY'S 2008 INTRAVENOUS MEDICATIONS BOOK, 24TH ED. NO INFORMATION IS LISTED REGARDING COMPATIBILITY WITH THESE MEDICATIONS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ALARIS PRIMARY TUBING SET 20 DROP NONE FPA ALARIS

    Patients

    Seq Age Sex Outcome Treatment
    1 ALARIS PUMP WITH TUBING| PRIMAXIN| NORMAL SALINE| VANCOMYCIN