Description of Event or Problem · 1
BACKGROUND: MY GRANDSON IS A SPECIAL NEEDS PT. HE WAS REMAINED IN THE HOSPITAL FOR 6 AND A HALF MOS. HE HAS NUMEROUS HEALTH PROBLEMS; THE PRIMARY ILLNESSES ARE SHORT GUT SYNDROME AND A FEEDING INTOLERANCE. HE HAD A SECTION OF HIS SMALL INTESTINES REMOVED. WHEN PT WAS RELEASED FROM THE HOSPITAL, HE HAD A CENTRAL LINE AND AN NG TUBE; HE REQUIRED HOME HEALTHCARE AND INFUSION EQUIPMENT AND SUPPLIES FOR HIS TPNS, LIPIDS, AND FORMULA FEEDING. THE INFUSION COMPANY THAT THE HOSPITAL RECOMMENDED WAS: INFUSION PARTNERS. THE EQUIPMENT THAT THEY ISSUED TO US WAS: -ENTERNAL FEEDING PUMP- DR. ORDERED 25 ML PER HOUR CONTINUOUS FEEDS THROUGH AN NG TUBE. TWO EACH -GEMSTAR INFUSION PUMP- 1 FOR TPN AND 1 FOR LIPIDS. AFTER WE BROUGHT PT HOME, HE BEGAN VOMITING AND HAVING DIARRHEA, I REQUESTED THAT THE INFUSION COMPANY SUPPLY A FEEDING PUMP AND BAGS WITH AN ICE POUCH, SAME AS WAS USED IN THE HOSPITAL. THEY SENT ME A KANGAROO CONTROL ENTERNAL FEEDING PUMP. UPON CHANGING PUMPS, PT'S DIARRHEA AND VOMITING DISAPEARED. I RAN AN INFORMAL CHECK ON THE KANGAROO JOEY PUMPS DISPENSE RATE BY SITTING A TIMER FOR 1 HOUR AND DISPENSING IT A GLASS MEASURING DEVICE WITH ML MEASUREMENTS. THE PUMP SHOWED TO BE DISPENSING 30 ML PER HOUR EVEN THOUGH IT WAS SET TO AT 25 ML PER HOUR. I NOTIFIED INFUSION PARTNER OF THE DEFECTIVE PUMP. ON THE FOLLOWING MONTH, DOCTOR- ORDERED THAT PT FEEDS BE INCREASED BY 15ML ON ONE BOTTLE FEED AND 1 ML PER HOUR ON HIS CONTINOUS FEEDS. ON TEN DAYS LATER, WE HAD TO CARRY PT TO THE ER BECAUSE HE WAS VOMITING, HAD DIARRHEA AND THERE WAS BLOOD IN HIS STOOL. HE WAS ADMITTED TO THE HOSPITAL AND THEY DETERMINED THAT THE INCREASED IN FEEDS HAD OVERSTRESSED PT'S DIGESTIVE SYSTEM. THE DOCTOR ORDERED THAT HIS FEEDING BE SET BACK TO 25ML PER HOUR CONTINUOUS FEEDS. HE WAS RELEASED FROM THE HOSPITAL ON TWO DAYS LATER. UPON RELEASE, WE WENT WITH A NEW INFUSION COMPANY ARTEX MEDICAL, INC. BECAUSE OF THE MANY ERRORS, WHICH HAD OCCURRED THE INFUSION PARTNERS. ARTEX ISSUED: THERAPEUTICS ENTERALITE INFINITY- NG FEEDS 2 EACH -CURLIN MEDICAL, 4000 CMS- LIPID AND TPN FEEDS. SHORTLY AFTER PT WAS RELEASED FROM THE HOSPITAL, HE ONCE AGAIN BEGAN HAVING DIARRHEA, VOMITING AND ON NINE DAYS LATER, HE STARTED PASSING BLOOD IN HIS STOOL. HE WAS ONCE AGAIN ADMITTED TO THE HOSPITAL. AGAIN WE WENT OVER ALL THE DETAILS OF PT'S FEEDS, MEDICATIONS, AND NUMEROUS TESTS WERE PERFORMED. REMEMBERING THE CALIBRATION PROBLEMS WITH THE 1ST PUMP WE RECEIVED, I TESTED THE ZEVEX PUMP AND FOUND THAT IT WAS DISPENSING 27ML PER HOUR INSTEAD OF 25MLS PER HOUR. I REPORTED THIS TO THE INFUSION COMPANY AND THEY SENT ME OUT ANOTHER ZEVEX PUMP, WHICH THEY INDICATED WAS BRAND NEW OUT OF THE BOX. THEY BROUGHT ME SOME 60ML SYRINGES, SO I COULD DO MY OWN TEST. WHEN I ASK IF THEY HAD TESTED IT TO MAKE SURE IT WAS DISPENSING RIGHT, THEY SAID YES. I RAN BOTH PUMPS FOR AN HOUR AND THEY BOTH RAN 27MLS PER HOUR. I CALLED ARTEX BACK AND TOLD THEM WHAT I HAD FOUND AND THEY SAID THAT THEY WOULD BRING ME OUT ANOTHER PUMP, BUT THEY WOULD TEST IT FIRST BEFORE SENDING IT. LATER IN THE DAY, THEY SAID THAT THEY HAD TRIED 5 OTHER PUMPS AND NONE OF THE THEM WOULD DISPENSE 25ML PER HOUR THAT THEY WERE DISPENSING 26 MLS, AND THAT THE PUMPS COULD NOT BE CALIBRATED. THEY SAID THEY HAD THE ZEVEX REPRESENTATIVE THERE, AND THEY WERE GOING TO TRY ONE MORE PUMP. THEY SAID THAT THE PUMP HAD A + OR - 5% ACCURACY AND THAT THE KANGAROO PUMP HAD A +/- 10% ACCURACY. THIS WAS THE FIRST TIME ANYONE HAD EVERY TOLD ME THAT. I WAS OF THE IMPRESSION IF YOU SET A PUMP TO DISPENSE 25 MLS PER HOUR, THAT IS WHAT IT WOULD DO. I DID A CHECK ON THE KANGAROO PUMP THAT HAD BEEN PREVIOUSLY USED AND IT DISPENSED 22MLS PER HOUR. WE WERE BEING DISMISSED FROM THE HOSPITAL BUT WE DID NOT HAVE AN ACCURATE PUMP, SO I SET THE PUMP TO 23MLS PER HOUR AND IT DISPENSES 25MLS PER HOUR. HOWEVER THIS IS AN ACCIDENT WAITING TO HAPPEN. SINCE I HAVE NURSING STAFF AND THE DOCTOR'S ORDERS READ 25 MLS PER HOUR. I AM ADVISING THE STAFF OF THE PROBLEM WITH THE PUMP. BUT PT'S LAST HOSPITAL VISIT WAS DUE TO THE KANGAROO PUMP DISPENSING 22MLS PER HOUR AND WHEN WE WENT TO A NEW COMPANY, THE ZEVEX PUMP DISPENSING 27 MLS PER HOURS. HIS SYSTEM BECAME OVER STRESSED WITH THE 5ML DIFFERENCE. PT HAS A VERY SENSITIVE SYSTEM BECAUSE OF HIS MEDICAL CONDITIONS AND HE IS JUST A BABY. THERE ARE A LOT OF KIDS OUT THERE LIKE THIS PT, AND THEY MAY BE HAVING THE SAME PROBLEMS BECAUSE OF THE PUMP SETTING NOT BEING ACCURATE. AT THIS POINT I AM AFRAID TO TRY ANOTHER COMPANY. ARTEX SAID THAT THEY RELY ON THE SUPPLIER OF THE PUMPS TO INSURE THE ACCURACY. WE HAVE TO BE SO EXACT ON THE PREPARATION OF HIS FORMULA, YET THERE IS SUCH A VARIANCE ON THE ACCURACY OF THE DIFFERENT PUMPS DISPENSING RATE. IT IS SELF DEFEATING AND SENDS LUKE TO THE ER. PLEASE HELP, THESE KIDS NEED TO BE PROTECTED. TODAY, THE FOLLOWING MONTH, I CALLED THE ZEVEX COMPANY AND REPORTED THE PROBLEM WITH THE PUMPS TO THEM AND AM WAITING FOR A CALL BACK. THANK YOU, DOSE OR AMOUNT: 25ML PER HOUR; FREQUENCY: CONTINUOUS; ROUTE: OTHER. DATES OF USE: 2008. DIAGNOSIS OR REASON FOR USE: SHORT BOWEL SYNDROME/FEEDING INTOLERANCE. EVENT ABATED AFTER USE STOPPED OR DOSE REDUCED: YES.