Alaris Free flow incidents

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Fri, 12/23/2022 - 12:36
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Mohamed Sarg
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Joined: 01/16/2016 - 12:34
Alaris Free flow incidents

In a 30 days span we experienced multiple Alaris pump/Alaris tubing issues and wondering if anyone else is experiencing the same issue.

The issues identified were Alaris free flowing medications. This is happening mainly after the initial programming of the infusions. We did through investigation and we excluded user programming errors. We ran diagnostics and the pump doesn't even record it is free flowing. BD so far unable to replicate incidents and unable to find why.

We initially thought this was one-off but after we asked staff to monitor the infusion for the first 3 minutes we caught 4 more incidents.

We also had incidents where tube will bubble or leak and it is not tied to a specific lot number.

have any one experienced the same thing? I reported this to FDA and ISMP to share incidents.

Thank you all for your help and happy holidays.

Sincerely,
Mohamed

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