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.