Description of Event or Problem · 0
INITIATION OF NEW ICU MEDICAL IV PUMPS ON [REDACTED]. FOUR ISSUES TO REPORT FROM [REDACTED]-THE NEXT DAY: 1. MODEL NUMBER: 40002-04-03. SERIAL NUMBER: [REDACTED]. IV PUMP ALARMED DISTAL AIR, AND TUBING APPEARED TO HAVE A SMALL AMOUNT OF AIR NEAR THE CASSETTE. WHEN CASSETTE DOOR WAS OPENED, THE CASSETTE DID NOT STAY CLAMPED AND STARTED TO BOLUS THE MEDICATION. THE MEDICATION WAS NOREPINEPHRINE. PT WAS AN IMMEDIATE POST-OP CABG [CORONARY ARTERY BYPASS GRAFT] AND THE INFUSION WAS GOING THROUGH A 9F INTRODUCER, THEREFORE THE NOREPINEPHRINE BOLUSED TO GRAVITY THROUGH THE LARGE BORE. UNKNOWN AMOUNTS OF MEDICATION WERE INFUSED DURING THIS. PT'S BP WENT FROM 96/49 TO THE 180-190S/90S/-100S RANGE AND LASTED APPROX. 4 MINUTES. DURING THIS TIME PT IMMEDIATELY REPORTED SEVERE PALPITATIONS AND PRESSURE ON HER CHEST WHICH DID NOT RESOLVE FOR 20-30 MINUTES. 2. MODEL NUMBER: 40002-04-03. SERIAL NUMBER: [REDACTED]. POST OP OPEN HEART HAD PROPOFOL PUT ON STANDBY BY PRIMARY NURSE. PRIMARY NURSE DISCONNECTED THE PROPOFOL LINE AND FLUSHED THE IV CLEAR. THE PROPOFOL DRIP LINE WAS HOOKED BACK UP TO THE PATIENT WITH THE IV PUMP STILL ON STANDBY. THE NURSE ASSESSED THE IV 15 MINUTES LATER AND THE IV WAS FULL OF PROPOFOL AND CONTINUED TO INFUSE. 3. MODEL NUMBER: 40002-04-03: SERIAL NUMBER: NO PUMP INFORMATION. IV PUMP ALARMING DOWNSTREAM AIR OCCLUSION. RN ATTEMPTED TO CLEAR THE ALARM, BUT ALARM WOULD NOT CLEAR. ICU MEDICAL REP ON SITE TO ASSIST WITH NEW PUMPS. ICU MEDICAL REP ALSO COULD NOT CLEAR THE ALARM AND HAD TO CLEAR THE PROGRAMING OF THE PUMP IN ORDER TO CLEAR THE ALARM. THE PATIENT WAS ON A HEPARIN DRIP AND HAD A DELAY GETTING IT RESTARTED DUE TO THE TROUBLESHOOTING. CLEARING THE PROGRAMMING OF THE PUMP TO CLEAR A DOWNSTREAM OCCLUSION IS NOT ACCEPTABLE WHEN WE RUN CRITICAL DRIPS. 4. MODEL NUMBER: 40002-04-03. SERIAL NUMBER: [REDACTED] . THE RIGHT CHAMBER FLOODED WITH IV FLUID: THE CHAMBER BROKE.