Inadvertent residual IV med bolus

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

1 post / 0 new
Joanie Cook
Joanie Cook's picture
Offline
Last seen: 4 days 7 hours ago
Joined: 10/08/2015 - 14:06
Inadvertent residual IV med bolus

My student and I are evaluating a case where a patient received an inadvertent bolus of residual high-concentration norepinephrine which was still present in a port access line after an infusion. We occasionally get reports of similar events happening with propofol for patients coming out of the OR. And I recall that there was at least one published case many years ago involving a neuromuscular blocker. I'm wondering if anyone has had similar events at your hospital, and if you have any ideas how to "hard wire" preventing this type of event? Flushing is a routine and expected practice, but it's occasionally missed. Thanks!

Tags: