BEUDAMED
    FDA Adverse Event No answer provided Summary report: N

    ALARIS

    MDR report key: 16333962 · Received February 9, 2023

    Report

    Report Number
    16333962
    Event Type
    No answer provided
    Date Received
    February 9, 2023
    Date of Event
    December 22, 2022
    Report Date
    January 18, 2023
    Manufacturer
    CAREFUSION 303, INC.
    Product Code
    FRN
    Report Source
    User Facility report
    Reporter Location
    MA
    Reporter Occupation
    NURSE
    Health Professional
    Yes

    Narratives

    Description of Event or Problem · 0

    PATIENT ORDERED FOR MAGNESIUM SULFATE INFUSION X1. THIS RN PRIMED THE BAG OF MG AND ONCE THE CURRENTLY INFUSING ANTIBIOTICS WAS COMPLETED, HUNG THE BAG, PLACED THE TUBING IN THE PUMP, AND SET THE MEDICATION SPECIFIC RATES VIA THE PRE-PROGRAMMED ALARIS GUARDRAIL SETTINGS. THE TUBING WAS THEN ATTACHED TO THE PATIENT, THE INFUSION WAS STARTED, AND TUBING WAS UN-CLAMPED. I THEN STAYED WITH THE PATIENT TO WATCH THE DRIP CHAMBER TO WHICH I THEN NOTICED THE RATE WAS SIGNIFICANTLY FASTER THAN NORMAL. THE INFUSION WAS STOPPED, PATIENT DISCONNECTED, AND PUMP TURNED OFF. I DISCARDED THE TUBING AND MEDICATION, AND REQUESTED THE PATIENT¿S MD PLACE AN ADDITIONAL ORDER FOR MG. ONCE OBTAINED, I REPEATED THE SAME STEPS FOR MED ADMINISTRATION ON THE PUMP'S SAME PRIMARY CHANNEL AS PREVIOUSLY UTILIZED. ONCE THE INFUSION WAS STARTED, THE CHANNEL ALARMED MULTIPLE TIMES FOR "PATIENT SIDE OCCLUSION." THE INFUSION WAS STOPPED AGAIN AND THE IV TUBING WAS MOVED TO ANOTHER CHANNEL ON THE PUMP. THERE WERE NO ISSUES ASSOCIATED WITH THE INFUSION ONCE THE OTHER CHANNEL WAS UTILIZED. ONCE THE INFUSION WAS FINALLY COMPLETED, CLINICAL ENGINEERING WAS PAGED, AND THEY RETRIEVED THE PUMP TO ANALYZE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1462086 ALARIS PUMP, INFUSION FRN CAREFUSION 303, INC. 8015, 8100, 8120

    Patients

    Seq Age Sex Outcome Treatment
    1 30660 DA Unknown