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Prevent Uncontrolled, Rapid Infusion Rates: Confirm Infusions Are Connected to Pumps Before Opening the Clamp!

Problem: Within several weeks, an organization experienced three errors in which patients received uncontrolled intravenous (IV) infusions at rapid rates. As noted in the event descriptions that follow, the infusions were all associated with high-alert medications—heparin, propofol, and phenylephrine—that should have been administered at a controlled rate via a smart infusion pump. However, each infusion was found to be   mistakenly administered via gravity at a rapid rate of infusion, rather than connected to a programmed infusion pump with a defined rate of infusion. The patients required treatment after the events, but were not permanently harmed.

Event #1

A patient inadvertently received an entire 500 mL infusion of heparin (25,000 units/500 mL) within 1 hour. The error began when a nurse was to administer an intermittent antibiotic and heparin infusion to the patient. The hospital did not have enough infusion pumps for all infusions and did not require the use of an infusion pump for organization-defined “low risk” medications, including intermittent antibiotics. When starting the antibiotic and heparin infusions, the nurse confused the antibiotic and heparin lines, resulting in slow antibiotic administration through the infusion pump programmed to infuse the heparin, and rapid heparin administration via gravity. The patient received protamine to reduce the risk of bleeding from the rapid heparin infusion and recovered without incident.

Event #2

A patient received a rapid dose of propofol (500 mg/50 mL) that was intended to be administered as a continuous infusion at a much slower rate. A nurse had unclamped the IV administration set for the propofol infusion without noticing that the infusion was never connected to the programmed infusion pump. The entire propofol infusion was administered within minutes. The distracted and hurried nurse who made the error while preparing the patient to leave for a computed tomography (CT) scan had been assisting the patient’s primary nurse, who was caring for multiple trauma patients. After the error was discovered, the nurse acknowledged that the required safety steps for setting up the infusion, including tracing the IV tubing from the source infusion, through the pump, and to the patient, had not been followed.

Event #3

A patient accidentally received a bolus dose of phenylephrine (20 mg/250 mL) in the operating room (OR). An anesthesiologist noted a sudden increase in the patient’s blood pressure during the procedure, which helped identify the error. The phenylephrine should have been administered more slowly via an infusion pump. However, the pump had been alarming “air in line,” and to clear the alarm, the infusion was removed from the pump and the free-flow protection clamp was opened to remove the air in the line and to reprime the line. The infusion was never reconnected to the pump to re-engage the free-flow protection clamp after clearing the alarm, and the phenylephrine infused rapidly via gravity, causing the patient’s blood pressure to increase.

While each error has unique root causes, there were several contributing factors identified during investigation of the events:

  • Not having an adequate supply of infusion pumps available

  • Only using infusion pumps to deliver “high-risk” medications

  • Starting infusions without confirming the infusion rate

  • Failure to trace infusion lines before opening the clamp on the IV set to start or restart infusions

  • Distractions and time constraints during medication administration

  • Failure to respond appropriately to infusion pump alarms (e.g., “air in line” alarm)

Safe Practice Recommendations: The following strategies can be implemented to help prevent these types of errors within your organization, many of which can be included in a short, standard safety checklist for practitioners to follow when hanging or changing IV bags, bottles, or syringes.

Establish an expectation. Require practitioners to administer all continuous and intermittent infusions, whether medications or hydrating fluids and regardless of “high-risk” designation, using a smart infusion pump (exception: fluid resuscitation efforts).

Provide an adequate supply of smart infusion pumps. If necessary, purchase additional smart infusion pumps to facilitate utilization of a pump to deliver all medication infusions and hydrating solutions (ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps). Older infusion pumps without free-flow protected tubing should not be purchased or used.

Employ DERS. Maintain a complete drug library in smart infusion pumps, and require practitioners to engage the dose error-reduction system (DERS) when administering all infusions, including those deemed “low risk.”

Label lines. Label all infusion lines (and other access lines/catheters) at the point(s) of connection (e.g., above the pump and above the access point into the patient’s body).

Trace infusion lines. When infusions are started, reconnected, or changed (i.e., new bag/bottle/syringe), trace the tubing by hand from the solution container to the pump (and channel), to the connection port, and then to the patient to verify the proper infusion, pump/channel, and route of administration. Confirm that the infusion rate has been programmed accurately before starting the infusion.

Confirm before opening the roller clamp. After priming the tubing for infusions (or clearing air from the line), keep the roller clamp below the drip chamber closed until infusion lines have been traced to confirm the connection to the correct infusion pump and channel.

Respond appropriately to pump alarms. After troubleshooting an “air in line” alarm and clearing the line, ensure the tubing is placed back into the smart pump using DERS and then resume the infusion.

Provide handoff reports. Communicate with the care team, especially during handoffs or when someone other than the primary nurse or provider is helping to manage the patient’s infusions. Trace all access lines as part of the handoff.

Manage distractions and time constraints. Encourage staff to speak up in situations where they feel that time constraints or distractions are creating an unsafe environment in which an error may be more likely to occur.

Manage the environment. Identify, report, and mitigate environmental factors that impair the ability to practice in a safe and efficient manner. For example, provide proper lighting in patient treatment areas and rooms, and ensure the practitioner’s line of sight of both the patient and the pump is not obstructed.

Recognize and correct errors. Monitor patients for unanticipated events and investigate pump connections if clinical deterioration or an unexpected adverse effect is detected.

Share good catches. Share impactful stories and recognize staff for good catches, especially when harmful errors were prevented due to tracing the infusion line, catching a programming error, and/or engaging the DERS.

Use data from technology. Utilize data from infusion devices to monitor compliance, establish performance measures, and identify workarounds that impact compliance.

Educate staff. During orientation and ongoing training, educate staff about errors that have occurred when infusions are administered at a much faster rate because they were inadvertently not connected to an infusion pump. During nursing orientation, stress the need to trace infusion lines and practice tracing lines during periodic simulations.

Suggested citation:

Institute for Safe Medication Practices (ISMP). Prevent uncontrolled, rapid infusion rates: confirm infusions are connected to pumps before opening the clamp! ISMP Medication Safety Alert! Acute Care. 2022;27(15):1-3.