This is part two of a two-part blog.
A nurse's aide, when transferring a mother in labor to the delivery room, turned off the infusion pump delivering Pitocin, a drug administered intravenously to accelerate contractions. The aide removed the infusion set from the pump without first closing the manual clamp on the line. A free-flow infusion occurred, and the mother received nearly 35 times the prescribed amount of drug. The infant suffered organ damage and pneumonia and died four days later.
This incident happened in 1991.
A decade earlier, ECRI had warned about the dangers of IV free flow in a 1982 evaluation of infusion controllers. Free-flow, or unrestricted gravity flow, refers to the uncontrolled delivery of an infusion to a patient when a controlled or metered delivery was intended. Depending on the drug being administered, IV free flow can lead to death or serious patient harm. That's why the test criteria for our 1982 evaluation specified that infusion devices should provide safeguards to prevent uncontrolled flow.
Fast-forward to the decade after that incident. By the early 2000s, many infusion pumps included an effective free-flow protection mechanism to guard against this hazard. Today, such mechanisms are a standard safety feature.
But how many patients suffered harm in the meantime?
It's with that question in mind that we issued a challenge to industry within the pages of our Hazards report. The report identifies 10 health technology hazards that ECRI's experts believe warrant priority attention. In ECRI's view, several of the hazards listed could be mitigated—and possibly eliminated—by improved device designs or manufacturing quality processes. We encourage industry to rise to that challenge.
