Description of Event or Problem · 1
A MEMBER OF THE FACILITY'S NURSING STAFF REPORTED THAT A PATIENT DEATH OCCURRED AFTER A FAILURE WITH A COLLEAGUE INFUSION PUMP. UPON FURTHER INVESTIGATION WITH THE FACILITY, THE PATIENT WAS REPORTED TO BE A CARDIAC TRANSPLANT PATIENT THAT WAS IN THE CARDIOVASCULAR INTENSIVE CARE UNIT. A TRIPLE CHANNEL PUMP WAS IN USE INFUSING ISOPROTERENOL AT AN UNKNOWN RATE. THE NURSE REPORTED THAT PUMP WENT INTO AN UNKNOWN FAILURE. THE PATIENT CODED AND WAS RESUSCITATED BY THE MEDICAL STAFF. THE ASSISTANT NURSE MANAGER REPORTS THE PATIENT DID EXPIRE 12 HOURS AFTER THE PUMP FAILURE AND STATED THAT THE DEATH WAS NOT RELATED TO THE INCIDENT WITH THE PUMP. THE PUMP WAS NOT IDENTIFIED OR ISOLATED BY THE FACILITY. ALTHOUGH ATTEMPTS WERE MADE BY BAXTER SALES AND QUALITY MANAGEMENT TO OBTAIN ADDITIONAL INFORMATION FROM THE REPORTING FACILITY, DETAILS WERE NOT AVAILABLE REGARDING PATIENT DEMOGRAPHICS, STATUS, OR SET UP OF THE DEVICE. THE ASSISTANT NURSE MANAGER STATED THAT AN AUTOPSY WAS NOT PERFORMED.