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Confusion reported between AGGRASTAT (tirofiban) and heparin while using a two-channel pump



From the April 17, 2003 issue


Two-channel pump mix-up. A nurse was using a two-channel pump to infuse AGGRASTAT (tirofiban) through one channel and heparin through the other. While hanging a new bag for each solution, she inadvertently threaded the Aggrastat tubing through the channel already programmed for heparin, and vice versa. Luckily, a pharmacist noticed the error before patient harm occurred. While the risk of this type of error should be factored into the decision to purchase and use dual-channel pumps, the same error also could happen if two single-channel pumps on the same pole were in use. Adhere to the following practices to avoid errors: (1) hang one solution at a time; (2) physically trace the line from the solution, through the pump, and to the insertion site to validate the intended channel; (3) if a high-alert medication will be infused, require one clinician to hang the solution and ready it for infusion, and another clinician to independently validate the correct patient, dose/concentration, insertion site (route), and pump/channel settings; (4) consider labeling each channel with the product being infused, but avoid total reliance on the label to select the proper channel; and (5) never use a dual-channel pump to infuse solutions into two different patients. (Yes, we've occasionally observed this unsafe practice in inpatient and outpatient settings.)
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