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April 2005, Volume 35 Number 4 , p 18 - 20





  • What went wrong?

  • What precautions can you take?

    A PATIENT needed treatment with a skin graft after an infusion of phenytoin (Dilantin) infiltrated into his hand, permanently damaging nerves and tissue. His I.V. pump didn't sound an alarm during the infiltration.

    Another patient, a dehydrated 18-month-old receiving a bolus of I.V. fluid, suffered an infiltration that made her arm swell from her hand to her elbow. The pump's I.V. pressure setting was set at a level considered potentially unsafe for children and infants. No alarm sounded during the infiltration. The child was transferred to a pediatric facility, where the injury was evaluated for surgery.

    What went wrong?

    The Food and Drug Administration receives many medical device problem reports about I.V. infiltration (the leakage of I.V. fluid into subcutaneous tissue). Many reports indicate that an I.V. pump malfunctioned because infiltration didn't ...

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