The device involved in this incident has been requested but to date has not been received for evaluation. if the device is received, or if additional information pertinent to the incident is obtained a follow-up report will be submitted. as part of our manufacturing process, all device history records are reviewed and approved by quality, prior to release of product.
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The customer reported that when giving the initial feeding with the kangaroo pump, which was the first time the pump was being used with this patient, they noticed the screen looked different than usual.There was an interval bolus and some other words regarding a bolus on the pump¿s screen that they had never seen before.They continued to program the pump as they were accustomed to.The patient was to receive one bolus of 320ml at 320ml/hr.The pump did not alarm that the feeding was complete.Upon examining the tube feed container, they noted that more than 320ml was gone.They tried to clear the volume on the pump to see how much the patient had received but there was no option to view the amount of intake or to see how much the patient had took in.There was an entry for boluses administered which said one, but the patient had definitely received more than one bolus, it was more likely two boluses of tf.The kangaroo pump had continued to give the tf bolus every hour, so the patient received two 320 boluses instead of stopping after one feed.The nurse practitioner was notified right away and 350ml was removed from the patient¿s gastric tube.The patient reported feeling distended but better after the 350ml was removed.The patient¿s lungs were also auscultated for any crackles or adventitious sounds and none were noted.The patient did not vomit.
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