Description of Event or Problem · 1
PATIENT WAS ADMITTED TO ED FOR EVALUATION OF WEAKNESS RELATED TO COMPLICATED MEDICAL HISTORY. INTUBATION OF PATIENT WAS NECESSARY TO ADDRESS CURRENT RESPIRATORY STATUS. A FENTANYL DRIP WAS ORDERED TO BE DELIVERED THROUGH CENTRAL VENOUS LINE FOR SEDATION. NURSE SET UP IV LINE AND APPROPRIATELY FED LINE THROUGH ALARIS MODULE ON 8015 ALARIS PC. ROLLER CLAMP CONTROL ON TUBING WAS IN THE OPEN POSITION. AS SHE CLOSED THE MODULE DOOR, THE CHANNEL ALARMED "CLOSE DOOR SAFETY CLAMP OPEN" AND THE NURSE WAS UNABLE TO CORRECT THE ERROR. NURSE REMOVED THE TUBING FROM THE MODULE AND BELIEVED THAT THE TUBING WOULD AUTOMATICALLY CLAMP OFF AS EXPECTED PER USUAL PROCESS WHEN PUMP WAS CORRECTLY FUNCTIONING. NURSE THEN WENT TO FIND A REPLACEMENT FOR THE MALFUNCTIONING PUMP. PATIENT SUBSEQUENTLY RECEIVED FREE FLOWING OVERDOSE OF FENTANYL ADMINISTRATION, COMPLICATING PATIENT CONDITION AND CONTRIBUTING TO PATIENT DEATH.WHAT WAS THE ORIGINAL INTENDED PROCEDURE?ADMINISTRATION OF IV MEDICATION.DEVICE #1IS THIS A LABORATORY DEVICE OR LABORATORY TEST?NO.