Patient underload.The operator installed the kit without problems.At the end he started the priming of the circuit which did not signal any alarm.After connecting the patient, the operator started the procedure and a few seconds after com.Tec continuously signaled "low infusion pressure" alarm.By carefully checking the assembly of the kit they noticed that the drip chambers of the replacement fluids line filled completely because the pump segment (white connector) were glued in the opposite position.The white pump pumps in the direction of replacement fluids (see photo attached).Received 2 pictures, on the pictures it is visible that the tubing assembled to the transparent pump have been exchanged.Identified root cause: assembly failure.Result of risk assessment: potential hazard / hazardous situation: tube glued into wrong port of the pump adapter patient underload.Severity of the harm: catastrophic.Occurrence of the harm: improbable.
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