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As reported by the user facility: details of complaint (reported issue): "a nurse in the surgical medical intensive care unit reported that despite checking the connections and tubing at the beginning of her shift, the "anti-siphon" valve automatically loosened from the tubing 4 hours later, causing a vasopressor that was scheduled to be released at a high dose.Fortunately, there was no severe impact on the patient." 1.The report mentions "a vasopressor that was scheduled to be released at a high dose." could you confirm which of the following occurred: external leakage from the infusion set.The nurse had done her initial check at the start of the shift, and confirmed that all connections, lines and tubing's were properly secured.About 4h into her shift, she noticed a leak at the connection site of the anti-siphon valve.It appeared that the valve had become loose somehow from the adjacent tubing, which resulted in the leak.The infusion had been running continuously the entire time, although titration of the medication was performed as required.However, the infusion was never paused or restarted at a higher rate, so it is unlikely that the cause of the leak was a pressure surge.Patient was also turned and positioned during this time, which may have affected the connection of the asv to the tubing.2.Which vasopressor drug was being administered at the time of the incident? levophed.3.Did the anti-siphon valve (asv) become fully detached from the tubing, or was it partially loosened while still attached? partially loosened while still attached.The nurse stated that other than at the initial check, she did not manipulate the asv connection site until she noticed the leak.4.Was there any drug leakage observed at the level of the asv? yes.
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