Alert: Failure to use smart infusion (IV) pump safety limits may result in harm


Intravenous news: The Orange County Register report “UCI Medical Center failed to program drug pumps to stop a medication error, which could have contributed to the death of a kidney transplant patient, according to a federal inspection report released Thursday. The Centers for Medicare & Medicaid Services sent investigators in August to the teaching hospital in Orange after UCI reported the overdose. In July, an unidentified patient was given an anti-rejection drug at too fast a rate and later died of undetermined causes. The error was categorized as putting the patient in “immediate jeopardy,” which is the most serious category of patient harm. That status was lifted the next day after UCI made changes to how the pumps were used.

The report also found that, in June, an unidentified 10-year-old boy received 30 times the normal dose of a sedative after an anesthesiologist in training incorrectly programmed a pump. He survived but underwent two “rescue medications” to stabilize his heart. That pump has since been removed from widespread use.

Hospital Chief Executive Terry Belmont sent an email to hospital staff Thursday detailing changes made, including additional training and formation of a patient safety committee.

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