TRANSDUCER X8-2T

Description of Event or Problem

SITUATION: TRANSESOPHAGEAL ECHOCARDIOGRAM (TEE) PROBE RUBBER SHEATH WAS NOT INTACT WHEN PROBE REMOVED FROM PATIENT¿S ESOPHAGUS AT THE END OF PROCEDURE. TEE PROBE WAS INTACT PRIOR TO INSERTION. BACKGROUND: PATIENT UNDERWENT ROUTINE TEE WITH BITE BLOCK IN PLACE. WHEN PROBE WAS REMOVED AND CARDIOLOGIST PASSED THE PROBE TO ECHO TECH, SHE WIPED IT DOWN AS PER USUAL PRACTICE AND SHE NOTED A 1-1.5¿ PIECE OF THE PROBE COVERING (BLACK, SOFT RUBBER) WAS MISSING. SHE NOTIFIED THE CARDIOLOGIST AND THE REGISTERED NURSE (RN) WHO WERE ALSO AT BEDSIDE AND ALL LOOKED FOR THE PIECE IN THE BED, TRASH, LINEN, ETC. THE MISSING PIECE WAS NOT FOUND. THE PATIENT HAD A CT SCAN AND RESULTS DO NOT SHOW ANY ¿DISCERNABLE RADIOPAQUE FOREIGN OBJECT¿ OR EVIDENCE OF BOWEL OBSTRUCTION. THE TEE PROBE WAS SEQUESTERED AND SUBSEQUENTLY, BIOMED TOOK POSSESSION OF THE PROBE WITH INTENT ON SENDING BACK TO PHILIPS.