It was reported that bd gravity set valve malfunctioned.The following information was received by the initial reporter with the verbatim: 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.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.Of note, if the roller ball was wide open, the flush syringe did not empty the stop cock syringe.It followed the path of least resistance and pulled from the iv fluid bag.If we closed the roller ball at all, the stop cock syringe was aspirated into the flush syringe.
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