When something goes wrong with a patient or a med

The controlled drip that is emptying faster than the pump says

Bag says one thing, the pump says another, and it's 0300. What to check, who to call, and how to chart it so it holds up later.

7 min read built on 0 cases updated 2026-10-28

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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It's 0300. You check your fentanyl drip and the bag looks low, lower than it should be. Add up the pump's volume infused, the programmed rate and the history log and you get one number. The bag in front of you shows another. Below: what to look at, who to call, what goes in the chart.

Key points

  • Stop. Look before you touch anything. Write down the rate, the VTBI, the volume infused and the last few entries in the pump's event history, with the times.
  • Read the bag by its printed graduations. Write that number down too, with the time you read it.
  • Get a second nurse to look at the same bag, pump and line. Trace the tubing from the bag to the patient together.
  • Tell your charge nurse and pharmacy (or whoever your facility policy names). Leave the bag and tubing as they are until they tell you what to do with them.
  • Chart the numbers you saw and the people you told. Keep your theory about why out of it.

What to write

How it gets written How it could be written
Fentanyl drip discrepancy noted. Charge RN aware.0310: Fentanyl 1000 mcg/100 mL infusing at 10 mL/hr (100 mcg/hr) per order. Pump shows volume infused 42 mL since bag hung at 2000. Bag graduations read approx 40 mL remaining. Expected remaining approx 58 mL. Difference approx 18 mL. Charge RN J. Smith notified 0315.
Bag looks low, will monitor.0310: Bag visually reads approx 40 mL. Pump volume infused 42 mL, rate 10 mL/hr, no rate changes in pump history since 2000. Tubing traced bag to R forearm PIV with RN K. Lee: no leaks, all connections secure, dressing dry. Pharmacy notified 0320.
Reset pump volume.0325: Per charge RN J. Smith, pump volume infused not cleared. Bag and tubing kept at bedside for pharmacy review per policy. Infusion continued at 10 mL/hr.
Verified drip with oncoming RN.0700: Bedside handoff with RN M. Diaz. Checked together: order, bag label, concentration, rate 10 mL/hr, line traced to patient, bag reads approx 22 mL. Pump volume infused 112 mL since 2000 hang.
Patient comfortable on drip.0330: RASS 0, CPOT 1, RR 16, SpO2 97% on 2L NC. No change in sedation or pain scores from 2300 assessment.
Possible tampering.0310: Y-site port cap present, clamp position unchanged from 2300 check. No visible puncture or residue on bag. Findings reviewed with charge RN J. Smith.

Don't skip the patient assessment row. If the drug went in faster than the pump says, you'd expect more sedation. If it didn't go in at all, you'd expect more pain. Either way, how the patient was doing at that time is part of the picture.

Template

Chart note

[TIME]: [DRUG] [CONCENTRATION, e.g. 1000 mcg/100 mL] infusing via [PUMP/CHANNEL] at [RATE] mL/hr ([DOSE] mcg/hr) per order dated [ORDER DATE].
Bag hung [HANG DATE/TIME] by [RN NAME], labeled volume [BAG VOLUME] mL.
Pump display at [TIME]: volume infused [VOLUME INFUSED] mL, VTBI [VTBI] mL, rate [RATE] mL/hr.
Pump history since hang: [RATE CHANGES / BOLUSES / NONE, WITH TIMES].
Bag reads approx [BAG READING] mL remaining by printed graduations. Expected remaining based on pump volume infused: approx [EXPECTED] mL. Difference approx [DIFFERENCE] mL.
Line traced from bag to [IV SITE] with [SECOND RN NAME], [CREDENTIALS]. Connections [SECURE / FINDING]. Site [FINDING]. Dressing and linens [DRY / FINDING].
Patient at [TIME]: [SEDATION SCALE + SCORE], [PAIN SCALE + SCORE], RR [RR], SpO2 [SPO2]% on [O2].
[CHARGE RN NAME] notified at [TIME]. [PHARMACY / SUPERVISOR NAME] notified at [TIME].
Instructions received: [WHAT YOU WERE TOLD TO DO WITH BAG, TUBING, PUMP].
Action taken: [INFUSION CONTINUED / BAG REPLACED / BAG KEPT FOR REVIEW], at [TIME].
Next check: [TIME].

Message to charge nurse or manager

[DATE] [TIME]
Patient: [PATIENT IDENTIFIER PER POLICY], Room [ROOM]
Infusion: [DRUG] [CONCENTRATION] at [RATE] mL/hr, hung [HANG DATE/TIME].
At [TIME] the pump showed [VOLUME INFUSED] mL infused since hang. The bag reads approx [BAG READING] mL remaining. Expected approx [EXPECTED] mL. Difference approx [DIFFERENCE] mL.
Pump history shows [RATE CHANGES / BOLUSES / NONE] since hang.
Line traced with [SECOND RN NAME]: [FINDINGS].
Patient status: [SEDATION SCORE], [PAIN SCORE], vitals [STABLE / CHANGES].
Bag, tubing and pump currently [STATUS, e.g. kept at bedside, infusion running].
Please advise on next steps for the bag and pump per policy.
[YOUR NAME], [CREDENTIALS], [UNIT], [EXTENSION]

Incident or occurrence report narrative

On [DATE] at [TIME], during a routine infusion check, I observed that the remaining volume in the [DRUG] [CONCENTRATION] infusion bag did not match the volume infused shown on the pump.
Bag hung [HANG DATE/TIME] by [RN NAME]. Labeled volume [BAG VOLUME] mL. Ordered rate [RATE] mL/hr.
Pump display at [TIME]: volume infused [VOLUME INFUSED] mL, VTBI [VTBI] mL, rate [RATE] mL/hr. Pump history since hang: [ENTRIES WITH TIMES].
Bag graduations at [TIME]: approx [BAG READING] mL. Expected approx [EXPECTED] mL. Difference approx [DIFFERENCE] mL.
Line traced from bag to patient with [SECOND RN NAME] at [TIME]. Findings: [CONNECTIONS, SITE, LEAKS, PORT CAPS, CLAMPS].
Last handoff check of this infusion: [TIME], with [RN NAMES], bag read approx [VOLUME] mL at that time.
Patient assessment at [TIME]: [SEDATION SCORE], [PAIN SCORE], RR [RR], SpO2 [SPO2]%.
Notified: [CHARGE RN NAME] at [TIME], [PHARMACY NAME] at [TIME], [PROVIDER NAME, IF NOTIFIED] at [TIME].
Disposition of bag, tubing and pump: [WHAT WAS DONE, BY WHOM, AT WHAT TIME].
Pump serial or asset number: [NUMBER].
No pump settings were changed or cleared before notification. [OR: Settings changed at [TIME] by [NAME] as follows: [CHANGE].]

Words to avoid

Word or phrase Why it hurts Use instead
discrepancy notedSays something was off. Gives no dataBoth numbers and the difference, with the time
approximately (with no number)No figure means the reader has nothing to checkapprox 40 mL per bag graduations
per pumpThe pump shows several numbers. Which one?pump volume infused 42 mL, pump rate 10 mL/hr
verifiedWith whom? Compared against what?checked with RN K. Lee: order, label, rate, line traced
diversion, tamperingA conclusion you aren't in a position to reachWhat you saw: port caps, clamps, the label, the bag
errorLabels the event before anyone has reviewed itDescribe the mismatch in numbers
will monitorMonitor what? How often? Who?Rate, bag volume and RASS rechecked at 0400
awareWho was told, when, and what did they say?Charge RN J. Smith notified 0315, instructed to keep bag at bedside

Discrepancy noted with no numbers or times

The usual mistake: you chart a conclusion when you should chart what you saw. A note like discrepancy noted, charge RN aware tells the next reader that something was off. How far off? Compared with what? At what time? It doesn't say. Six months later nobody can rebuild what you saw, and that includes you.

The second mistake is quietly fixing the numbers. A nurse resets the VTBI or clears the volume infused so the pump matches the bag, and charts nothing. Smart pumps keep an event log with a timestamp for every keypress. So now the pump shows an edit at 0312 and the chart has no note to explain it. That gap looks worse than the original mismatch.

Bags and pumps also disagree for plenty of innocent reasons. That's why the raw numbers matter so much:

  • Overfill. Manufacturers often put more fluid in the bag than the label says, so a 100 mL bag may hold a bit more.
  • Priming. Priming the tubing takes volume out of the bag. The pump never counts it as infused.
  • Tubing or bag changes. A new line gets primed from the same bag, so more volume leaves uncounted.
  • Boluses and titrations. If someone gave a bolus from the drip, or changed the rate and didn't write it down, the math in your head is wrong.
  • VTBI set low on purpose. Plenty of nurses set the VTBI below the bag volume so the pump alarms before the bag runs dry. The VTBI field was never meant to tell you how much is in the bag.
  • Bag height and tubing position. On some systems these can affect delivery.
  • A leak. Wet sheets, a damp dressing or a disconnected Y-site can account for the missing volume.

If you chart only the numbers and the times, everyone who reviews the event later can check each of these explanations. If you chart a conclusion, they can't.

Bottom line

Chart the two numbers, the time, who looked with you and who you told. And don't touch the pump until someone has seen it.

Official guidance

  • On high-risk infusions, the double check should include physically tracing the line from the bag through the pump to the patient and matching what you see to the order. (AHRQ PSNet, Pharmacy Times)
  • Check pump settings at the bedside during shift report. The outgoing and oncoming nurse both look at the pump. (Nursing Advanced Skills, WTCS, Pharmacy Times)

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.

  • We are supposed to co-sign on the drip rate during hand-off, but not on how much is left in the bag. I think I'll suggest making that a policy going forward. Also, maybe clearing the volume on the pump after every bag is changed... unless it's a CRRT patient, we don't clear the volume

    r/nursing on Reddit: Fentanyl Discrepancy... need feedback please! reddit

  • At my institution, Epic is programmed to pre-print the next label about 3 hours before a continuous drip is projected to run out — and that applies to all continuous infusions, even purge fluids. It calculates this based on the documented rate and volume, so if the rate is changed, Epic recalculates

    r/nursing on Reddit: Nurses — question about scanning/documenting continuous drips in Epic reddit

  • If it’s a 100 ml bag that’s already run 80, 80+15 =95. As to why not 10, usually for me I try to pick a volume that won’t let it run dry but also won’t beep/alarm so quickly that’d I’d have to go back and add more volume. I work in infusions so at least when my med is done, it’s just switching to th

    r/nursing on Reddit: Stupid question about IV pumps reddit

  • Because it's a titrated drip and needs to go in at a consistent rate. What would happen if I took an NS continuous at 200ml/hr and plugged it into the y-site at the top of the line, right next to the pump?

    r/nursing on Reddit: ICU Propofol infusion question reddit

Other guides

Advice, not law.