Description of Event or Problem · 1
WHILE SETTING UP ONE OF THE BAXA EM 2400 PUMP, THE TUBING FOR MAGNESIUM 8% WAS PLUGGED INTO THE PORT ASSIGNED TO HEPARIN 100 UNIT/ML AND VISA VERSA. THE SECOND CHECK PERSON, WHO ALSO PRIMES THE MACHINE, DID NOT NOTICE THE SWITCH. IT WAS EVENTUALLY CAUGHT 12 HRS LATER WHEN SOMEONE NOTICED THE HEPARIN BAG WAS FULL AND THE MAGNESIUM BAG WAS EMPTY MORE THAN USUAL. THERE WERE NO PATIENTS WHO RECEIVED HEPARIN WHO SHOULD HAVE RECEIVED MAGNESIUM, BUT 16 PATIENTS WHO RECEIVED MAGNESIUM WHO SHOULD HAVE RECEIVED HEPARIN. FORTUNATELY, THE ORDERED HEPARIN WAS MINIMAL CONCENTRATION OF 1 UNIT/ML SOLUTIONS WHICH EQUATED TO VERY LOW AMOUNTS OF MAGNESIUM IN THE ERROR. ALL PATIENTS HAD A MAGNESIUM LEVEL DONE WITH 6 MILDLY ELEVATED LEVELS, THE MAX BEING 2.7. WE ARE VERY HIGH USERS OF THE BAXA PUMP EM 2400. WE USE TWO OF THE PUMPS AND MAKE ALL PRODUCTS PER YEAR WITH THEM. WE ALSO USE TOTAL PORTS WHICH WE KNOW IS ABOVE THE AVERAGE USE. THIS IS THE SECOND TIME IN OUR HISTORY THAT THIS TYPE OF ERROR HAS OCCURRED - FIRST ONE ALSO REPORTED TO MEDWATCH OVER A YEAR AGO. BASED ON RCA CONDUCTED ON THIS ERROR, BESIDES THE INTERNAL THINGS FOUND, WE WISH THE MANUFACTURER TO CONSIDER THESE POTENTIAL IMPROVEMENTS: PORT NUMBERS MORE CLEARLY VISIBLE AND COLORED RATHER THAN RAISED CLEAR PLASTIC, BARCODED PORTS DURING SET UP, OPTION TO HAVE BAXA SELL PRE-SET UP PORTS AND TUBING, OR UNIQUE PORT CONNECTIONS OR TUBES TO HELP DISTINGUISH THEM APART.