BD Alaris Primary IV Tubing Malfunction

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 jrufo@ismp.org. 

2 posts / 0 new
Log in or register to post comments
Last post
Fri, 02/18/2022 - 22:30
#1
Danielle Pray
Danielle Pray's picture
Offline
Last seen: 2 years 4 months ago
Joined: 06/30/2020 - 03:22
BD Alaris Primary IV Tubing Malfunction

Has anyone encountered a malfunction in the primary IV tubing with the secondary IVPB backglowing into the primary tubing and solution.

Here's what we know.

- 4 occurence with chemo agents

- The RNs had the primary set up, attached the secondary (primary tubing was in the pump but pump turned off). When the secondary was unclamped the medication from the secondary back flowed (past the back flow check valve) and into the primary solution rather quickly.

The secondary bag was higher than the primary.

This was tested off the pump with the sequestered tubing and same issue.

- this was tested with NS on multiple lots to identify the lot number as the packaging was tossed. We could not recreate.

We tested again on the sequestered tubing the next day work NS and it did not happen.

Makes me think the back flow check valve has an issue with the rubber or what ever component was in it amd once wet swelled up again. Or the testing is failing because ots the chemo agents affecting the valve.

The BD rep has not heard of other occurrences.

Packaging of different lot for picture of the back check valve I'm referring to.

Attach files :
Image icon screenshot_20220218-192926_word.jpg

Tags: 

Top