GLUCOSE SENSOR
Received Dec 5, 1997 · Event occurred Nov 12, 1997
Report 2028008-1997-00001 · MDR key 136092
Device
Generic name
Glucose Sensor
Manufacturer
Via Medical Corp.Model number
GLU1ACatalog number
301607
Lot number
UNK
Patient
UNKNOWN
- Shock, Insulin
Narrative
Description of Event or Problem
VIA MONITOR THAT HAD BEEN ATTACHED TO AN ARTERIAL LINE WAS DISCONNECTED AND ATTACHED TO THE MID PORT OF A CENTRAL VENOUS CATHETER LINE POST-OPERATIVELY; THE PROXIMAL PORT (WHERE THE VIA SHOULD HAVE BEEN INSTALLED) WAS BEING USED TO DELIVER DEXTROSE TO THE PT. THE VIA MONITOR WAS INDICATING READINGS >600 MG/DL. NURSE ON DUTY BEGAN TREATING FROM THESE VALUES AND GAVE SUBSTANTIAL VOLUME OF INSULIN TO REDUCE THE GLUCOSE LEVEL. SHE CONTINUED THIS TREATMENT FOR APPROX. 6 HRS. A BLOOD SAMPLE WAS TAKEN TO THE LAB AND INDICATED PT BLOOD GLUCOSE LEVEL WAS 17 MG/DL THE NURSE MAKING THE REPORT ( A DIFFERENT NURSE THAT THE ONE WHO HAD USED THE VIA PRODUCT ON THE PT) INDICATED THAT THE DEATH WAS NOT A RESULT OF THE MISTREATMENT BASED UPON THE MISAPPLICATION OF THE VIA MONITOR.