Model Number PRI TUBING |
Device Problem
Excess Flow or Over-Infusion (1311)
|
Patient Problem
Venipuncture (2129)
|
Event Date 06/07/2019 |
Event Type
Injury
|
Manufacturer Narrative
|
Additional info: level after the event 3.5 ekg k+ level after the event 3.5 ekg.Although requested, device has not been received.A follow up report will be submitted with failure investigation results should the device be received for evaluation.
|
|
Event Description
|
It was reported there was a potassium over infusion event; the potassium appeared to be infusing too quickly.A primary infusion of potassium (kcl) 10meq in 100 ml was initiated, however the nurse noted 60ml had already infused several minutes after the start of the infusion.The patient required ekg (no changes), a repeat potassium level (normal range) and continuous monitoring (no changes noted).No lasting harm was reported.Although requested there were no further details of the event received.Received a copy of the customer medwatch report of (b)(6) 2019 that stated:"10meq/100ml potassium chloride started at 0659.Rn stayed with patient as drip started.At 0710, bag "seemed too empty for time hanging".Channel off button pressed.After stopping the pump to stop potassium from infusing, the potassium continued to slowly infuse.Roller camp on tubing had to be closed and patient was unhooked from iv immediately".
|
|
Event Description
|
It was reported there was a potassium over infusion event; the potassium appeared to be infusing too quickly.A primary infusion of potassium (kcl) 10meq in 100 ml was initiated, however the nurse noted 60ml had already infused several minutes after the start of the infusion.The patient required ekg (no changes), a repeat potassium level (normal range) and continuous monitoring (no changes noted).No lasting harm was reported.Although requested there were no further details of the event received.Received a copy of the customer medwatch report of 6-27-2019 that stated:"10meq/100ml potassium chloride started at 0659.Rn stayed with patient as drip started.At 0710, bag "seemed too empty for time hanging".Channel off button pressed.After stopping the pump to stop potassium from infusing, the potassium continued to slowly infuse.Roller camp on tubing had to be closed and patient was unhooked from iv immediately.".
|
|
Manufacturer Narrative
|
Additional info: the suspect has been changed from a disposable set to an instrument.Please reference the new manufacturer number 2016493-2019-00905 from e-mdr: (b)(4).
|
|
Search Alerts/Recalls
|