It was reported that there was an excessive delivery of heparin during continuous renal replacement therapy with a prismaflex machine.It was reported that within 15 minutes of starting infusion, 10,000iu of heparin was completely infused to the patient.There was no patient injury or medical intervention associated with this event.No additional information is available.
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Based on the records of the log file, the estimated blood loss of 190 ml wasn¿t returned to the patient.The actual device was inspected on site by a qualified baxter technician.A simulated treatment and a full functional check including the operation of the syringe pump was performed and the device passed.The reported condition was not verified.The event history log review showed no keystrokes, programming, or use related events that indicated and/or contributed to the reported issue.The analysis of the treatment log file did not find any evidence of malfunction of the prismaflex device in the delivery of the anticoagulant fluid.A service history review revealed no indication that the parts replaced during servicing caused or contributed to the reported event.Should additional relevant information become available, a supplemental report will be submitted.
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