TPA didn't infuse

[JeffTheRN]

Odd situation that was brought to my my attention the other night....

On my regular shift 7a-7p, I get a post lysis patient from IR (she had a clot in her left popliteal) around 3p. She came to me from IR with TPA at 100/hr (rate to be decreased to 50/hr @ 4pm) and heparin at 15/hr (pump rates). She had been complaining of cramping pain in her left calf down to her foot from the time she came to the unit, until the time I left with very little relief from anything I pushed.

I handed her off at 7p and left. The next time I come in to work, 3 days later, one of the veteran nurses pulls me off to the side and tells me that she took the patient over at 11p the night that I left. She also told me that the TPA hanging had never infused!!

When I left my shift that night, I cleared my totals for the pumps and all totals matched according to the prescribed rates. But the TPA bag was nearly still FULL. Unfortunately I did not catch this, nor did the nurse that had the patient for 4 hours after me. (still with me here....?)

The way the "veteran nurse" explained it to me was, the pump was going through the motions and counting mls/hr in it's head, but was never actually infusing anything! ARGHHH!!!

On the patient's end, the four hours I had her and the four hours the next nurse had her, she had a FAINT doppler-able post tib on the affected side, but no DP...I guess when the mistake was caught, all pulses came back beautifully soon after.

So, I guess I am just throwing this out there that, even though the pump says it's pumping, ALWAYS check the DRIP CHAMBERS! ugh.

[TLCinCICU]

Thanks for sharing the story. Out of curiosity, what was the brand/maker of pump?

[joeyzstj, LPN]

So everything was connected and properly in place? Was it just a pump/casette malfunction causing it to not pump?

[JeffTheRN]

Yes, everything was connected properly. The pumps are oooooooooold. We have actually trialled one new manufacturer , hopefully the deal will happen. At this time, I cannot recall the manufacturer of the current old pumps, but will update tomorrow.

[SWEnfermera]

Thank you so much for sharing your story. It gives us all an opportunity to learn something valuable here. I worked at one hospital once as an agency nurse that also had very old pumps (unfortunately I can't remember the maker, but they were small, square, and brown). One good thing about these pumps was that any manufacturer's tubing could be used with them. If the roller clamp was above the pump, and closed, the pump could not sense this and looked as if it was working properly. It could only sense a problem when the roller clamp was below the pump. I learned this too the hard way. Fortunately for me and the patient, it was just on a maintenance fluid and not on a medication drip.

[iluvivt, BSN, RN]

Thank you for sharing. Reminds us all to check your entire system from the bag down to the site. After 27 years I still do this and I look at at least 60-100 set-ups every shift. Since I go into every unit I get to see everything and I catch quite a bit.

[JeffTheRN]

The pump manufacturer was Baxter (not sure if I can put that here or not), but the pump was removed from service and sent down to clinical engineering.

[Okami_CCRN, BSN, RN]

Baxter had to pull all our pumps and reprogram them because some where not calibrated accurately, or they broke and never gave the error signal.

Now we are getting new ones that hopefully wont have all these problems

[KellyCCRN]

we had similar problems with baxter pumps. Thankfully a little over a year ago we switched to alaris pumps....they took quite a while to get used to as you have to actually program in the pt and the med ( they have a tracking system) but they are wonderfull!