A one-time dose of fentanyl was initiated at 0505 to be given prior to intubation.The dose was initiated, and the intubation process was started.Upon hanging a saline flush, the nurse discovered that there was a crack in the clave/ med tubing and the fentanyl had puddled on the ground below the syringe pump.A re-dose of fentanyl was required, and the intubation was traumatic as a result of the failed infusion of the first dose.The neonatal nurse practitioner was at the bedside and was notified immediately of the event.The charge nurse was also made aware and was at the bedside.
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