CATHETER, UMBILICAL ARTERY
Received Oct 18, 2022 · Event occurred Sep 23, 2022
Report 15629324 · MDR key 15629324
Device
Product problems
- Defective Device
Patient
10 DA · Male
- No Clinical Signs, Symptoms or Conditions
- No Clinical Signs, Symptoms or Conditions
Narrative
Description of Event or Problem
LINE CHANGE WAS DUE FOR UMBILICAL ARTERY CATHETER (UAC) FLUIDS, THE LINE WAS CHANGED AND HUNG AT 1:20 AM. BLOOD PRESSURES WERE APPROPRIATE AND LINE SEEMED TO BE WORKING FINE. THEN BLOOD PRESSURE MEANS WERE 66/63 AND THEN NOT READING. THE LINE WAS ASSESSED AND FLUSHED AND SEEMED TO BE BETTER. THE DIAPER CLOTH UNDER THE LINE WAS NOTED TO BE WET BUT MULTIPLE REGISTERED NURSES (RNS) COULD NOT FIGURE OUT WHERE THE WET FEELING WAS COMING FROM. LINE FLUSHED AGAIN AND NO LEAKING TO BE NOTED. LINE CHECKED AGAIN AT 0400 BECAUSE IT WAS NOT WORKING AGAIN AND LEAKING NOTED FROM THE TUBING (NOT AT A LUER LOCK CONNECTION SITE). REGISTERED NURSE CALLED PHARMACY AND ORDERED NEW UAC FLUIDS. LINE TUBING WAS THEN CHANGED AND MALFUNCTIONING TUBING SAVED.