FDA Adverse Event
Other
Summary report: N
BD ALARIS PUMP
MDR report key: 24689210
·
Received March 25, 2026
Report
- Report Number
- MW5185838
- Event Type
- Other
- Date Received
- March 25, 2026
- Date of Event
- March 9, 2026
- Report Date
- March 17, 2026
- Manufacturer
- CAREFUSION 303, INC.
- Product Code
- FRN
- Report Source
- Voluntary report
- Reporter Location
- MD, US
- Reporter Occupation
- NURSE
- Health Professional
- Yes
Narratives
Description of Event or Problem · 0
ADDITIONAL INFORMATION RECEIVED ON 04/22/2026 FOR MW5185838 TO CORRECT THE PROCODE TO FRN.
Description of Event or Problem · 0
THE RN (REGISTERED NURSE) WAS TITRATING WEIGHT-BASED NOREPINEPHRINE. WHEN TRYING TO TITRATE FROM 0.06 MCG/KG/MIN TO 0.09 MCG/KG/MIN THEY MISSED A DECIMAL AND PROGRAMED 0.9 MCG/KG/MIN AT 2156. THIS INCREASED THE RATE FROM 11.8 ML/HR TO 177.2 ML/HR. THE PATIENT HEART RATE INCREASED TO 120S, BLOOD PRESSURE INCREASED TO 181/105. RN IDENTIFIED THE MEDICATION ERROR AT 2204. A SIMPLE MISSED DECIMAL ALLOWED THE RN TO TITRATE BY 16 TIMES THE PREVIOUS DOSE WITH NO GUARDRAILS TO CHECK THE MISTAKE.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 745239 | BD ALARIS PUMP | PUMP, INFUSION | FRN | CAREFUSION 303, INC. |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 65 YR | Male | Other | NOREPINEPHRINE |