Description of Event or Problem · 1
A POTASSIUM IV WAS HUNG TO BE ADMINISTERED BY A SIGMA SPECTRUM PUMP. SOON AFTER ADMINISTRATION, AN UPSTREAM OCCLUSION ALARM OCCURRED. THE NURSE RETURNED AND CHECKED THE LINES AND RESTARTED THE INFUSION. LATER IN THE SHIFT DURING A ROUTINE CHECK, IT WAS NOTED THAT EVEN THOUGH THE PUMP WAS STILL OPERATING, NO MEDICATION WAS BEING DELIVERED. ON INSPECTION THE NURSE NOTED A CLAMP ON THE UPSTREAM SIDE OF THE RUMP WAS STILL CLOSED. THE PUMP WAS REMOVED AND SENT TO BIOMED FOR TESTING. THE BIOMED STAFF CONFIRMED THAT A SECOND UPSTREAM OCCLUSION COULD GO WITHOUT ALARM IF PUMP WAS RESTARTED IN THE OCCLUDED STATE. SIGMA WAS CALLED AND THEY STATED THAT THIS IS NORMAL AND CORRECT OPERATION BASED ON THE TECHNOLOGY USED TO DETECT UPSTREAM OCCLUSIONS ON THESE PUMPS AND IS STATED AS SUCH BOTH IN TRAINING AND IN THE OPERATIONS MANUAL. THIS IS BEING REPORTED NOT BECAUSE THE PUMP MALFUNCTIONED, IN FACT IT PASSED ALL OPERATIONS TESTS, BUT BECAUSE THE STAFF FOUND IT COUNTER INTUITIVE AND POSSIBLY DANGEROUS THAT A DEVICE COULD BE INADVERTENTLY RESTARTED IN AN ALARM STATE AND NO LONGER RECOGNIZE THAT ALARM.