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It was reported that the bd alaris secondary gravity set had air bubbles / air in line.The following information was provided by the initial reporter: also, this morning, same unit had an issue with the secondary tubing.A patient was scheduled for iv tylenol and had primary ns kvo infusion already on the alaris pump.They verified set-up and secondary tubing unclamped and hung above primary tubing of ns.The alaris pump alarmed that infusion was complete, but the nurse found tylenol had not been administered and the pump had pulled the volume from the ns.They discarded the set and started new ns primed with secondary iv tylenol, manually clamped the primary ns bag prior to administering the iv tylenol.With that clamping, the secondary infusion then ran correctly.Additional information received from the customer: could you please provide a further description of the issue? it has happened twice in the past week.Neither of the specific tubing was saved, and the lot number is unknown.This was in reference to bd ref#10016073, secondary tubing set.Below is a summary of the incident: ¿primary rn hung iv tylenol as secondary infusion as ordered.A few minutes later, the alaris pump began alarming for air-in-line.When primary rn assessed the medication infusion, the primary iv fluid had infused instead of the tylenol.Primary rn verified that all clamps were open and that the primary iv fluids were hung lower than the secondary.Rn attempted to re-administer secondary medication after moving the infusion to a new alaris pump and channel and watched the infusion immediately after starting.Once again, the primary fluids began infusing instead of the secondary.Primary rn brought additional rn into the room to assess the problem.Per the additional rn, she had the same issue with a different patient a week prior when trying to infuse the secondary and could only infuse the medication properly when physically clamping off the primary infusion tubing with a kelly clamp.Second rn also mentioned that friends at other institutions mentioned having the same problems with secondary iv tubing.Primary rn able to infuse medication by clamping line, medication administered appropriately.¿.
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