It was reported that bd gravity set valve malfunctioned the following information was received by the initial reporter with the verbatim: i wanted to bring to your attention an issue we had this morning at union.A provider attached a phenylephrine syringe to the three way stop cock of the bd gravity iv set.Administered 50mcg phenylephrine.Then attached a 10cc syringe to the distal side port and withdrew a flush and subsequently pushed it.Not long after that, the patient experienced significant and concerning hypertension.With investigation, the phenylephrine syringe was found to be empty attached to the three way stop cock.We grabbed a few other packages of iv tubing and were able to recreate what happened.I am attaching a video here.In the end, the back check valve failed and the phenylephrine syringe was drawn up into the flush syringe and roughly 1000mcg was pushed as a bolus unknowingly.
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