Description of Event or Problem · 1
UPON HANGING NEW BAG OF TPN FOR A TPN DEPENDENT PATIENT, SIGMA PUMP WAS READING "AIR IN LINE" WHEN THERE WAS NO AIR IN THE LINE. THE LINE WAS REPRIMED AND PUMP WAS STILL READING AIR IN LINE. RN CHANGED THE LINE TO 4 OTHER SIGMA PUMPS IN THE ROOM. ALL PUMPS WERE READING AIR IN LINE WHEN NO AIR WAS IN LINE. CHARGE RN TO BEDSIDE TO TRY TO RESOLVE PROBLEM AND HAD THE SAME PROBLEM WITH ALL THE PUMPS READING AIR IN LINE. AS A RESULT, THE PATIENT'S BLOOD SUGAR LEVEL DROPPED. FOUND NEW PUMP THAT WAS NOT READING AIR IN LINE AND RN WAS ABLE TO BEGIN INFUSING TPN.THIS FACILITY HAS HAD MULTIPLE SIMILAR EVENTS WITH THIS PUMP. THE FACILITY HAS BEEN WORKING WITH THE MANUFACTURER DIRECTLY FOR ALMOST A YEAR BUT THE PROBLEMS CONTINUE ON A REGULAR AND CONSISTENT BASIS AND ACROSS MULTIPLE NURSING UNITS. INITIAL AND ADDITIONAL EDUCATION HAS BEEN PROVIDED TO STAFF. EXTRA RESOURCES, INCLUDING A CLINICAL STAFF MEMBER, HAVE BEEN ADDED IN AN EFFORT TO ADDRESS THE ISSUE, BUT THE PROBLEMS CONTINUE. THE FACILITY IS CONCERNED REGARDING THE DELAY IN THERAPY, WHICH SOMETIMES HAS RESULTED IN THE NEED FOR ADDITIONAL MEDICAL CARE FOR THE PATIENT. PATIENTS AND STAFF HAVE VERBALIZED FRUSTRATION WITH THE PUMP (PATIENTS ARE UPSET THAT THE PUMP ALARMS FREQUENTLY AND STAFF ARE CONCERNED THAT THEY ARE UNABLE TO DISTINGUISH BETWEEN A CRITICAL ALARM AND A NON-EMERGENCY ALARM BECAUSE THE ALARM TONES ARE IDENTICAL).