Secondary lines require "primary" attention.

An incident report received from an intensive care unit involving the administration of a secondary infusion is reprinted, with permission, and includes material from an ISMP Canada Safety Bulletin (ISMP Canada, 2005). The incident highlights a general shortcoming of many infusion pumps: lack of the capability to recognize primary versus secondary infusions. Reliance on practitioner vigilance to ensure appropriate administration adds to their already demanding practice. Secondary lines require "primary" attention from manufacturers to enhance infusion pump design and, in the interim, by all practitioners using infusion pumps with such limitations.