IV free-flow--still a cause for alarm

A nurse's aide, in 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. Free-flow infusions can have tragic consequences when a potent drug is involved. Although other causes of overinfusion and free-flow exist, such incidents are typically associated with removing a disposable intravenous (IV) infusion set from an infusion device without first closing the manual clamp. We first raised this issue in our 1982 Evaluation "Infusion Controllers" and have emphatically and repeatedly addressed it in Health Devices and other ECRI publications. Yet, hospitals continue to report free-flow infusions, a problem that can be addressed by both hospitals and device manufacturers. In this article, we describe the causes of free-flow--both user error and device design; report numerous incidents, some resulting in death; and provide recommendations for reducing the likelihood that such problems will continue to occur.