BEUDAMED
    FDA Adverse Event Injury Summary report: N

    AVI

    MDR report key: 77878 · Received February 26, 1997

    Report

    Report Number
    77878
    Event Type
    Injury
    Date Received
    February 26, 1997
    Date of Event
    August 5, 1996
    Report Date
    August 13, 1996
    Manufacturer
    3M AVI INC.
    Product Code
    FRN
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    User Facility report
    Reporter Location
    OK, US
    Reporter Occupation
    NURSE

    Narratives

    Description of Event or Problem · 1

    PT DISCOVERED IN VENTRICULAR TACHYCARDIA. STAFF, ON INVESTIGATION, FOUND PUMP INFUSING POTASSIUM PIGGYBACK AT 800+CC/HR. UNKNOWN HOW MUCH POTASSIUM HAD INFUSED AT THAT RATE. PT WAS HYPOTENSIVE BUT RESPONDED POSITIVELY TO CALCIUM CHLORIDE AND REVERTED TO SINUS RHYTHM. BLOOD PRESSURE NORMALIZED. THE PUMP WAS SET UP WITH AN NS FLUSH BAG ON THE MAIN LINE AND THE POTASSIUM PIGGYBACKED INTO THE NS. THE NURSE WHO HUNG THE PIGGYBACK OBTAINED A NEW PUMP. IT WAS PLUGGED IN. HE STRUNG THE NS AS THE PRIMARY IV BUT NOT SET A RATE. THE PIGGYBACK HAD ABOUT 80CC OF FLUID TO INFUSE AND WAS SET AT 60CC/HR. ORIGINAL PUMP BATTERY WAS FOUND TO BE DISCONNECTED INTERNALLY.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 AVI INFUSION PUMP FRN 3M AVI INC. 480 *

    Patients

    Seq Age Sex Outcome Treatment
    1 43 YR Life Threatening| R