Free flow associated with electronic infusion devices: an underestimated danger

Accidental, uncontrolled free flow after removal of administration sets from electronic infusion devices (EIDs) has only occasionally been reported. Recent evidence indicates that this problem is far more widespread and serious than previously understood. Well-documented cases of accidental death and serious injury have now come to light and are a particular cause for concern. Many of the EIDs commonly used in hospitals incorporate sets that offer no protection if someone removes the set from the device without first closing the set's flow control clamp. Because the problem has infrequently been reported and the risk is not well appreciated, only minimal warnings are issued about the problem by manufacturers. Standard intravenous tubing sets and other nonprotected EID sets are less expensive than protected sets and some hospitals have acquired EIDs that use unprotected sets without an adequate understanding of the risks of free flow (i.e., fluid overload and drug toxicity). Therefore critically ill patients receiving certain types of intravenous fluids or critical care drugs may be at great risk of injury when an overinfusion occurs. This article provides a better understanding of the extent of the problem and offers suggestions for minimizing or eliminating the problem.