Malfunctioning IV Devices Prove Fatal

The Joint Commission on Accreditation of Healthcare Organizations is sending a safety bulletin to more than 5,000 hospitals nationwide to warn staff of the dangers of infusion pumps.

Hospitals could loose their Medicaid accreditation if they cannot document the safe use of the equipment. Infusion pumps, when operating incorrectly, can deliver lethal bursts of medicine, allowing a rapid gush of medicines or liquids into patients. An inexpensive safety feature that clamps the intravenous line is needed to fix this malfunction. An estimated 200,000 pumps nationally need this clamp to operate properly.

In nearly every case involving patient harm from an infusion pump, a nurse failed to attach a roller-clamp to the intravenous line. This results in a sudden gush of medication called free flow.

Fatal overdoses from this oversight are not uncommon. The Chicago Tribune found 39 patients died and 373 were injured last year from the medication free flow.

The US Food and Drug Administration licenses infusion pumps and released a public health advisory in 1994 recommending an adhesive warning be placed on each pump. The warning should have outlined potential free-flow hazards but the advice was widely ignored.

Conflicting federal and state standards make the problem more difficult. In 38 states, hospitals are not required to publicly disclose patient deaths or injuries caused by free-flow or any other medical error.

Although the American Hospital Association opposes a mandatory recall of all free-flow pumps, hospitals have been encouraged to buy new models with build in protections.

The nation's largest infusion pump manufacturer, Baxter International, said they support safety initiatives. However Baxter investigators determined that inadequate training and carelessness by nurses cause the vast majority of drug overdoses delivered through Baxter infusion pumps.

Baxter has encouraged hospitals to upgrade pumps with safety precautions, which are included on all current models.

Information from the Chicago Tribune

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