[1682]
Ivac 560 iv infusion pump in use (staff did not mark which pump was in use), continuously alarming and not delivering amount of solution ordered. Clinical engineering notified tocheck the pump. Biomedical engineer noted that total parenteral nutrition (tpn) solution leaking onto floor. Verified that pump was functioning correctly but that iv tubing had a hole in it below the clear plastic connector. Iv therapist verified that tubing had been hanging more than 12 hours iv therapist identified that a small rubber disc which normally is in the center of the quarter-size white opaque disc was missing and that hole in tubing haf allowed air to get into line. Tubing was connected to pic line (peripheally-inserted central line) in the patient. No injury to patient. Patient did receive the ordered solution over approx one hour. Tubing has been saved the risk management officedevice labeled for single use. Patient medical status prior to event: fair condition. There was not multiple patient involvement. Invalid data - on device service/maintenance. No data - regarding date last serviced. Service provided by: invalid data. Invalid data - service records availability. Invalid data - regarding whether event presents imminent hazard. Invalid data - whether device used as labeled/intended. Device was not evaluated after the event. Method of evaluation: no data. Results of evaluation: no data. Conclusion: no data. Certainty of device as cause of or contributor to event: unknown (cannot determine). Corrective actions: none or unknown. The device was not destroyed/disposed of.
Patient Sequence No: 1, Text Type: D, B5