GELMAN PRESSURE TRANSDUCER PROTECTOR

Description of Event or Problem

FOUR DIALYSIS PTS AT A CLINIC BECAME INFECTED WITH HEPATITIS. RN SUSPECTS FAILURE OF TRANSDUCER PROTECTORS. ALL PTS USED SAME HEMODIALYSIS MACHINE. BLOOD FOUND INSIDE INTERNAL PRESSURE TRANSDUCER PROTECTOR OF THE LEVEL DETECTOR MODULE. RN SAID THEY HAVE EXPERIENCED MANY T.P'S BACKING UP WITH BLOOD BUT ARE UNAWARE OF ANY INCIDENTS OF ACTUAL RUPTURED T. P. MEMBRANES. THREE OTHER MACHINE WERE FOUND WITH BLOOD INSIDE THE INTERNAL T.P.