EDRN32

I actually did some research today and discovered that this is one of the problems with Alaris pumps. IN 2007 Cardinal Health recalled thousands of these pumps d/t similar events. I guess there was a malfunction with occluder springs ( little devices inside the module that regulate the flow of the fluid). There were even 2 deaths reported. I guess when the modules were assembled some of them even came without the springs while other ones came with broken, bent or otherwise damaged parts. What I was not able to find was list of serial numbers of the pumps affected but some of the pumps at this facility definitely are from that era. I went to the company's website as well as FDA and in both cases lists of SN were removed without the explanation. I will try to approach my boss with this next week. I agree with you that this should be a learning opportunity but unfortunately you should have seen mu superiors after this ( they were out for blood). I'm pretty sure I will get disciplined somehow just not sure how severe it will be.

So to clarify: the door was closed and the pump was not running but the contents were flowing in the patient or NOT flowing into the patient?

Hello all, I work at one of the busiest ER's in the city. Very chaotic and disorganized. I have been a nurse for about 9 yrs and 6 of those I have worked in this kind of setting, so I would consider myself somewhat experienced nurse. Several days ago I had a very unpleasant experience of making a med error. Very dangerous one too and I don't even know how it happened. I was attempting to start an IV insulin on a pt that came with BS above 600. As I was setting up the pump my charge nurse was trying to move the patient ( and the bed ) to the other side of the room because the cardiac monitor on this side was not working. As I always use another nurse to check my insulin with me I asked the second nurse to verify it with me. ON my surprise when I looked up toward the insulin bag hanging more than 2/3 's of the bag was missing. The bag was spiked, tubing was of course primed and it was inserted into the pump. It was connected to the patient but I did not yet program the pump so I had no clue how the medicine could have gotten to the patient. Probably about 40-50 units have infused into the patient. We use Alaris pumps and I remember I had some trouble closing the door on one of the channels. I have administered IV insulin many times with the same pump never had this happen ( Thank God). Patient did fine. We monitored her BS every 15 min, gave her 1/2 amp of glucose and started her on D10 . She was admitted to ICU for monitoring but her stay was uneventful. She was moved to medical floor the next day. Now my job ( and maybe my license) are in jeopardy. I already spoke to my boss twice but she is being very cautious as to what she says to me about this and she told me not to talk about this. She told me that I'm to expect some kind of corrective action ( not sure what this means) and that this is a very serious matter. I asked her if I'm going to be fired or if there will be any kind of action taken against my license and she didn't comment on this just told me " she wants me to be successful". She says there will be an investigation and she will talk to me next week. I'm worried sick. I feel better knowing patient is ok but I can't even sleep at night knowing that I might lose my license. Even losing my job would be devastating for me because ER nursing is what I have done and what I see myself doing for the rest of my life. I'm a single mom and my job is the only source of income for me and my daughter. Not sure what I'm going to do if I can't do nursing anymore. My mind is going wild. I would appreciate any kind of advice or if you have any thoughts about this please share. Anybody had similar experience or have heard of any? Thanks