BEUDAMED
    FDA Adverse Event Other Summary report: N

    ALARIS PUMP

    MDR report key: 24414861 · Received February 23, 2026

    Report

    Report Number
    MW5184215
    Event Type
    Other
    Date Received
    February 23, 2026
    Report Date
    February 19, 2026
    Manufacturer
    CAREFUSION 303, INC.
    Product Code
    FRN
    Report Source
    Voluntary report
    Reporter Occupation
    UNKNOWN
    Health Professional
    *

    Narratives

    Description of Event or Problem · 0

    ALARIS-CAREFUSION PUMPS ARE UNABLE TO IDENTIFY BETWEEN A 1 AND 3 ML SYRINGE WHEN A 3 ML SYRINGE IS PLACED ON THE PUMP. THIS LEADS TO ACCIDENTAL INFUSION ERRORS. WE HAVE HAD SEVERAL REPORTS OF PUMPS ACCIDENTALLY BEING PROGRAMMED WITH THE 1 ML SELECTION INSTEAD OF THE 3 ML SELECTION AND THE MEDICATION INFUSES FASTER THAN INTENDED. IN THIS INSTANCE WE HAD A PT ON A LOW DOSE OF ALPROSTADIL (0.01 MCG/KG/MIN; RATE OF 0.09 ML/HR) REQUIRING A 3 ML SYRINGE IN ORDER TO INFUSE SUCH A LOW RATE. SEVERAL SYRINGES WERE PROGRAMMED OVER MULTIPLE DAYS AND NOTICED 2 TIMES WHERE THE SYRINGE (WHICH SHOULD HAVE LASTED APPROX 24 HRS) RAN OUT IN 4 HRS AND THE 2ND TIME RAN OUT IN 8 HRS. IN THOSE INSTANCES, THE PT RECEIVED APPROX 3-6X THE INTENDED DOSE. NO HARM TO THE INFANT WAS REPORTED. THIS IS NOT THE FIRST TIME THIS HAS HAPPENED WITH A PROSTADIL AND OTHER MEDICATIONS. PUMP HAVING MORE THAN ONE SYRINGE OPTION TO SELECT - NURSING NOT BEING AWARE THAT THERE ARE 2 SYRINGE SIZES TO SELECT FROM. NURSING NOT KNOWING THAT THE SYRINGE SIZE SELECTED AFFECTS THE INFUSION RATE, BUSY ENVIRONMENT, SMALL WORKING ENVIRONMENT, LOW LIGHTING, BUSY PT LOAD. (B)(6), PHONE: (B)(6), EMAIL: (B)(6). SUBMISSION ID: (B)(4). PT CODE: 4582. DEVICE CODES: 1311, 1670. REF REPORT: MW5184216.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    473465 ALARIS PUMP PUMP, INFUSION FRN CAREFUSION 303, INC.

    Patients

    Seq Age Sex Outcome Treatment
    1 NA Unknown ALPROSTADIL.