Description of Event or Problem · 0
IT WAS REPORTED THAT THE INFUSION OF AMIODARONE ENDED SOONER THAN EXPECTED. PER REPORT, THIS OCCURRED THREE TIMES ON SAME PATIENT WHERE THE CLINICIAN NEEDED TO REPLACE THE INFUSION WITH A NEW AMIODARONE BAG SOONER THAN EXPECTED: ON (B)(6) 2024 AT 1410, 2030, AND ON (B)(6) 2024 AT APPROXIMATELY 0430. DUE TO THE EVENT, THE PATIENT REPORTEDLY BECAME BRADYCARDIC AND HYPOTENSIVE, "BUT IT CAN'T BE DEFINITIVELY LINKED TO THE OVER INFUSION OF AMIODARONE" ACCORDING TO THE REPORT. IT WAS REPORTED THAT THE PHYSICIAN (CARDIOLOGIST) WAS NOTIFIED, AND NO FURTHER INTERVENTIONS WERE ORDERED. THE PHYSICIAN THEN ORDERED TO HANG ANOTHER BAG OF AMIODARONE TO INFUSE USING A NEW PUMP MODULE AT 0524. BD (BECTON DICKINSON) RECEIVED ADDITIONAL INFORMATION. IT WAS REPORTED THAT ON (B)(6) 2024 AT 2059, AMIODARONE DRIP WAS HUNG "PER PROTOCOL (1 MG/MIN X 6 HOURS THEN 0.5 MG/MIN X 18 HOURS)." PER REPORT, THE 500 ML BAG SHOULD HAVE LASTED THE FULL 24 HOURS. THE RN (REGISTERED NURSE) DID TITRATE IT DOWN TO 0.5 MG/MIN AT 0305, "WHICH IS CORRECT." HOWEVER, THE BAG REPORTEDLY RAN DRY ON (B)(6) 2024 AT 1410. PER REPORT, IT IS BELIEVED THAT "THE NURSE JUST HUNG A NEW BAG WITHOUT QUESTIONING THAT IT SHOULDN'T HAVE RUN DRY ALREADY." BY THE TIME NIGHT SHIFT CAME ON, THE BAG RAN DRY AGAIN AT 2030. HOWEVER, THE NIGHT NURSE KNEW THAT THE PROTOCOL WAS INITIATED AT 2059 THE DAY PRIOR SO IT WOULD MAKE SENSE THAT THE BAG WOULD BE DRY AROUND THIS TIME. THE CARDIOLOGIST REPORTEDLY WANTED TO CONTINUE RUNNING AMIODARONE AT 0.5 MG/MIN FOR ANOTHER 24 HOURS. THEREFORE, THE NURSE OBTAINED ANOTHER 500 ML BAG OF AMIODARONE AND HUNG IT. AT 0421, HOWEVER, THE BAG WENT DRY AGAIN. THE NURSE KNEW THIS ISN'T NORMAL BECAUSE AT 0.5 ML/MIN, THE BAG WOULD HAVE BEEN ENOUGH FOR MORE THAN THE 24 HOURS. CHECKING EPIC (ELECTRONIC MEDICAL RECORD) UNDER INFUSION VERIFY, LOOKING AT THE IV PROGRAMMING, EVERYTHING LOOKED THE WAY IT WAS SUPPOSED TO, PER REPORT. IT WAS THEN THAT THE HOSPITAL STAFF DID AN INDEPENDENT INVESTIGATION BY QUARANTINING THE PUMP AND THE CHANNEL AND RAN SALINE TO PROGRAM AS AMIODARONE. IT WAS NOTED THAT IT WAS INFUSING WELL OVER THE 16.7 ML/HR. THAT IT WAS SUPPOSED TO. THE CARDIOLOGIST WAS NOTIFIED AND WANTED TO CONTINUE THE AMIODARONE DRIP SO ANOTHER BAG WAS HUNG ON A NEW PUMP AND CHANNEL AT 0524. THE ROOT CAUSE FOR THE REPORTED ISSUE OF AN OVER INFUSION OF AMIODARONE IS ATTRIBUTED TO A DAMAGED THIRD-PARTY BEZEL BY ELITE BIOMEDICAL THAT WAS FOUND TO BE PRODUCING UNREGULATED FLOW DURING THE INVESTIGATION TESTING.