When something goes wrong with a patient or a med

Changing the bag on a fentanyl drip without losing count

A bag change is four numbers that have to add up. Most notes have none of them, and pharmacy finds out later.

7 min read built on 0 cases updated 2026-11-02

Written by a med-surg RN, ten years, day shift. Why there is no name on it · How this guide is made

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You're hanging a new bag or syringe of fentanyl, hydromorphone or midazolam on a drip that's still running. The old bag still has drug in it, and some of that gets wasted. The new bag starts at full volume. The pump has to match the order. Each of those is a number. Your note should show them adding up, and it should show what the second nurse actually checked.

Key points

  • Before you stop the old bag, read the pump's total volume infused for that bag. Write it down. Then look at what's left in the bag or syringe and write that down too.
  • Waste what's left in front of your witness. Chart the measured amount, the method, and the witness's full name and credentials.
  • Before the new bag goes up, check its label against the order: patient, drug, total amount, total volume, concentration, expiration.
  • Program the pump, or confirm the program that's already there. The second nurse then checks it against the order on their own. They read the screen and the order themselves.
  • Chart the new bag with its own starting volume, dose rate, mL/hr rate and VTBI. The next bag change gets reconciled against those numbers.

What to write

Stopping the old bag

How it often gets written How it could be written
Fentanyl bag empty, new bag hung.1500 fentanyl 2500 mcg/250 mL (10 mcg/mL) stopped at 75 mcg/hr (7.5 mL/hr). Pump volume infused this bag: 196 mL. Remaining in bag by graduation: approx 58 mL.
Versed syringe changed.0300 midazolam 50 mg/50 mL (1 mg/mL) syringe stopped at 2 mg/hr (2 mL/hr). Pump volume infused: 44 mL. Remaining in syringe: 6 mL by syringe markings.
Dilaudid drip continued, bag swapped.0700 hydromorphone 10 mg/100 mL (0.1 mg/mL) bag removed. Pump cumulative volume infused this bag: 81 mL. Measured remaining: 19 mL.

The waste

How it often gets written How it could be written
Wasted remainder w/ RN.58 mL fentanyl 10 mcg/mL (580 mcg) wasted into [unit drug disposal container] at 1505. Witness: Jane Ortiz, RN, observed measurement and disposal.
Waste verified.6 mL midazolam 1 mg/mL (6 mg) expelled from syringe into disposal container. Witness Mark Chen, RN, read syringe volume and watched disposal. Waste entered in [dispensing cabinet] at 0307.
Waste done later, RN unavailable.19 mL hydromorphone 0.1 mg/mL held in sealed bag at bedside, labeled, in direct view. Witnessed waste 0725 with L. Brooks, RN. Delay due to second RN in rapid response.

Hanging and programming the new bag

How it often gets written How it could be written
New bag hung, pump checked.1510 new fentanyl 2500 mcg/250 mL (10 mcg/mL), pharmacy label checked against order for pt name, DOB, drug, concentration, exp. New tubing primed. Pump: fentanyl 75 mcg/hr = 7.5 mL/hr, VTBI 250 mL, volume infused cleared.
Double checked with RN.Program independently verified by J. Ortiz, RN: read order in MAR, read label, read pump screen (drug, concentration, dose rate, mL/hr, VTBI). Matched.
Restarted, pt tolerating well.Infusion restarted 1512. Interruption 12 min. RASS -1, RR 14, SpO2 96% on 2L at 1530.

Template

Bag or syringe change note

[DATE] [TIME] Continuous [DRUG] infusion bag/syringe change.

OLD BAG/SYRINGE
Drug and concentration: [DRUG] [TOTAL AMOUNT] / [TOTAL VOLUME] mL ([CONCENTRATION] per mL).
Hung: [DATE HUNG] [TIME HUNG].
Rate at stop: [DOSE RATE, e.g. 75 mcg/hr] = [mL/hr] mL/hr.
Pump volume infused this bag: [VOLUME INFUSED] mL.
Remaining by measurement: [REMAINING] mL = [REMAINING DOSE].
Remaining disposed of per waste note at [WASTE TIME].

NEW BAG/SYRINGE
Drug and concentration: [DRUG] [TOTAL AMOUNT] / [TOTAL VOLUME] mL ([CONCENTRATION] per mL).
Pharmacy label checked against order: patient name, DOB, drug, concentration, expiration [MATCHED / DID NOT MATCH, SEE NOTE].
Tubing: [NEW TUBING PRIMED / EXISTING TUBING, DATE OF LAST CHANGE].
Pump program: [DOSE RATE] = [mL/hr] mL/hr, VTBI [VTBI] mL, volume infused cleared [YES/NO].
Independent check by [WITNESS FULL NAME], [CREDENTIALS]: read order, label and pump screen. [MATCHED / DISCREPANCY, SEE NOTE].

Infusion stopped [STOP TIME], restarted [RESTART TIME]. Interruption [MINUTES] min.
Post-change assessment at [TIME]: sedation score [SCORE], RR [RR], SpO2 [SPO2] on [O2], pain [SCORE].

Witnessed waste note

[DATE] [TIME] Witnessed waste, [DRUG] [CONCENTRATION] per mL.
Source: [BAG / SYRINGE / TUBING] from infusion hung [DATE HUNG] [TIME HUNG].
Amount wasted: [mL] mL = [DOSE].
Method: [DISPOSAL CONTAINER OR METHOD PER UNIT POLICY].
Witness: [WITNESS FULL NAME], [CREDENTIALS]. Witness observed volume measurement and disposal.
Waste entered in [DISPENSING CABINET NAME] at [TIME].
[IF DELAYED: Remaining drug held [WHERE AND HOW SECURED] from [TIME] to [TIME]. Reason for delay: [REASON].]

Message to charge nurse or pharmacy when the numbers do not reconcile

[DATE] [TIME]
To: [CHARGE RN NAME] / [PHARMACY CONTACT]
Patient: [ROOM] [MRN]
Drug: [DRUG] [TOTAL AMOUNT] / [TOTAL VOLUME] mL, dispensed [DATE] [TIME].

At bag change [TIME]:
Pump volume infused this bag: [VOLUME INFUSED] mL.
Measured remaining: [REMAINING] mL.
Expected remaining from label volume: [EXPECTED] mL.
Difference: [DIFFERENCE] mL.

What I checked: [PUMP HISTORY / RATE CHANGES / TUBING / SITE / OTHER].
Remaining drug wasted at [TIME], witnessed by [WITNESS FULL NAME], [CREDENTIALS].
New bag hung [TIME], program verified by [SECOND RN FULL NAME].
Requesting review of discrepancy per unit process.
[YOUR FULL NAME], [CREDENTIALS], [EXTENSION]

Words to avoid

Word or phrase Why it's a problem What to write instead
remainder, rest of bagNo amount, so the count can't be closedThe measured mL and the dose, e.g. 58 mL (580 mcg)
verified, double checkedDoesn't say what was checked or by whomProgram verified by [NAME], RN: order, label, pump screen matched
witness presentBeing in the room is different from watching the wasteWitness observed measurement and disposal
bag changedOne event, no numbersStop time, volume infused, remaining, new bag details
per protocolThe reader can't tell which protocol or which settingsThe actual dose rate, mL/hr and VTBI
approx standing aloneFine for reading graduation marks on a bag, but not as the only numberPair it with the pump's volume infused for the same bag
tolerating wellGives no dataSedation score, RR, SpO2, pain score with time
new bag hung (with no concentration)Concentrations differ by unit and by batchDrug, total amount, total volume, mcg/mL or mg/mL

A waste note with no numbers in it

The most common mistake is a note with no numbers in it. Something like bag changed, waste completed with RN. It's true. Nobody can check the count from it.

Every opioid or benzo drip bag has to balance:

volume hung − volume infused = volume remaining = volume wasted

If your note has only one of those numbers, or none, nobody can close the loop later. Not you, not the pharmacist reconciling the dispensing cabinet, not the nurse who does the next bag change. Say the cabinet record shows 250 mL dispensed and the waste record says remainder. Now there's an unexplained gap between those two entries. Even if everything you did at the bedside was right.

Three things make the gap bigger:

  1. Overfill. Pharmacy bags often hold a bit more than the label says, so expect the pump's volume-infused counter and the label volume to be a little off. Write the remaining volume you actually measured. Not the number you calculated from the label.
  2. Titration. Rate changed six times this shift? Then one rate times the hours won't give you volume infused. Use the pump's cumulative total for that bag, and clear it when you hang the new one.
  3. The pump wasn't reset. If nobody clears volume infused or resets the reservoir volume for the new bag, your numbers carry over into the next nurse's. They won't make sense.

The second-nurse check has its own weak spot. If the witness signs without looking at the order, the pump screen and the label, the signature adds nothing. So say in your note what the witness looked at.

Bottom line

Write down every volume: hung, infused, remaining, wasted. Then the numbers add up and nobody has to ask you.

Official guidance

One caveat. The Hopkins source is a home-infusion handout for patients, not a hospital nursing policy. It's here because it agrees with the other source on these steps. The policy that applies to you is your own facility's.

What this rests on

No published decision turned up for this question. We looked, and the searches are in the record. So this article stands on published guidance and on how the question is asked on the floor, not on a court opinion. That is a weaker footing than the rest of the guide, and you should know it before you rely on it. The decisions behind the other articles are all in one place.

From nurses online

Quoted as written. Opinion, not a source.

  • Man all the time I’ve spiked through bags of narcotics or dropped a bottle of a narcotics and just wasted the whole thing and made a comment saying “nurse dropped vial of morphine, morphine on the ground.” At most I’ve taken a picture of my mistake as proof aka look there’s a whole bag of fentanyl l

    r/nursing on Reddit: I made a PCA pump mistake and im freaking out reddit

  • I can just do better next time with what I’ve learned :) Archived post. New comments cannot be posted and votes cannot be cast. Share ... tip for any continuous fluids: program the pump to infuse 20-30mls less than the volume of the bag.

    r/nursing on Reddit: Heparin drips: New Grad reddit

  • I’ve come in and found at handoff a nimbex drip that had the rate programmed as the dose and essentially bolused the entire bag in. I’ve also seen a versed bag hanging on a pump programmed for fentanyl. Big errors happen when you rush. Co-signing helps hold everyone accountable and keeps the patient

    What are some hard rules of medication administration that should never be broken? : r/nur reddit

  • She told me to go settle my new admit and she would hang my drips for me. Later that night, my fentanyl tubing ran dry when the pump said there should have been 10ml left in the bag still. In that moment, I was annoyed and didn’t even think about how suspicious that was. It has recently occurred to

    r/nursing on Reddit: Med diverter recently caught on my unit. reddit

Other guides

Advice, not law.