Accidental free flow of IV fluids on Smart Pumps

PLEASE NOTE:   Posts made to this forum should not be considered as the expressed opinions of, nor should be considered endorsed by, the Medication Safety Officer’s Society (MSOS) or the Institute for Safe Medication Practices (ISMP). 

Make sure your email is up-to-date
In order to continue to receive updates from MSOS, as well as forum posts and other valuable information as a member of MSOS, please be sure to update your email address with us, whenever it changes. If you need assistance doing so, please send an email to jgold@ismp.org. 

6 posts / 0 new
Log in or register to post comments
Last post
Mon, 04/04/2016 - 10:38
#1
Marilyn Hargett
Marilyn Hargett's picture
Offline
Last seen: 1 week 1 day ago
Joined: 12/10/2015 - 13:29
Accidental free flow of IV fluids on Smart Pumps

Hello,
I am at a lost as to what to do next. I desperately need your expertise…. We have had probably 5-6 incidents of inadvertent free flow of IV fluids over last year. Staff open the door and forget to clamp tubing first. I have tip sheets posted, I bring it up every other week in nursing orientation and again at 60 day orientation. I give examples of the events in our system of the error. What else can I do? I am at a lost as to why staff open the door before clamping. I cannot comprehend this as a seasoned nurse……

We have many inexperienced nurses in our hospital at the present time.
Can you share any addtional tools that have been significantly helpful in your organization?
I look forward to hearing from you.
Thank you
Marilyn Hargett MSN, RN

Top