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  1. Cohen, Michael R. RPH, MS, ScD

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A 58-year-old man undergoing surgery experienced a sudden decrease in arterial pressure for no apparent reason. After he was treated with vasopressors and his blood pressure stabilized, the staff realized that a nitroglycerin infusion had flowed into his I.V. access via gravity and the bottle was empty. Noticing a gap at the top of the infusion pump door, they found that the upper flange part of the tubing had been loaded improperly, disarming the mechanism that prevents free-flow. The pump database revealed that the pump had alarmed and displayed an error message during setup, but the message reported a possible occlusion, so the free-flow problem wasn't recognized and the alarm was overridden.


In a simulated clinical setting, investigate how improperly loaded tubing could affect the performance of your infusion pumps. If you uncover problems, report them at ismpinfo@ismp.org. All reports will be forwarded to the Food and Drug Administration and the device manufacturer. Your facility may also want to contact its infusion pump vendor to see if representatives are aware of such risks with their pumps.




Schroeder ME, et al. Tubing misload allows free flow event with smart intravenous infusion pump. Anesthesiology. 105(2):434-435, August 2006.