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A 2-year-old boy being treated for pneumonia was receiving an infusion of D5l0.45NSS. His nurse set the controls on the infusion pump for a rate of 40 ml/hour, then left the room.
When she returned 20 minutes later, the boy was playing with the pump's controls. Checking them, she saw that he'd changed the rate to 370 ml/hour. She quickly stopped the infusion and checked the amount of solution left in the I.V. bag. She calculated the boy had received 130 ml of solution in 20 minutes.
The excessive amount didn't harm the boy. But if drugs had been added to the solution, the increased rate could have had serious consequences.
This error serves as a reminder that patients themselves (adults as well as children) can inadvertently cause errors. So to prevent an error such as this, check an infusion frequently. Use an infusion pump only if it has an audible alarm and stops the infusion when the rate is changed. And when using an infusion pump with a child, be sure you place it out of his reach.