CUROS GREEN CAP

Description of Event or Problem

GREEN ALCOHOL CAP NOTED ON CHEST TUBE AT THE PLEURAL SPECIMEN PORT (NEAR ATRIUM NOT STOPCOCK) FOR PATIENT IN ROOM (B)(6) BY DAYSHIFT RN. PATIENT HAD CONTINUOUSLY INCREASED SUBCUTANEOUS AIR TO CHEST AND NECK. GREEN CAP REMOVED AND PATIENT STATED TO RN, ~WHATEVER DID YOU DO THAT JUST MADE IT SO MUCH EASIER TO BREATH? ~. DR INFORMED RN THERE SHOULD NEVER BE A GREEN CAP ON THAT SITE AS IT OPENS TO CIRCUIT AND CAN ACTUALLY LET AIR IN. PATIENT ACQUIRED SO MUCH SC; HE REQUIRED BILATERAL GILLS WITH WOUND VACS. GETINGE OASIS CHEST TUBE AND CUROS GREEN CAP. CHEST TUBE MANUFACTURER DOES NOT ADVISE ONE WAY OR THE OTHER TO USE THESE CAPS, AS THEY HAVE NEVER HAD THIS REPORTED TO THEM. REP FROM 3M/SOLVENTA DID NOT RETURN CALLS X3 WITH VOICEMAILS AFTER ESTABLISHING INITIAL EMAIL CONTACT. INSTRUCTIONS FOR CHEST TUBE DO NOT MENTION USING CAPS, BUT INSTEAD SWABBING THE SAMPLING PORT WITH ALCOHOL PRIOR TO AND AFTER COLLECTION OF SAMPLES. AFTER REMOVING CAP, DEVICE FUNCTIONED AS IT SHOULD. WE BELIEVE THAT THE CAP MAY HAVE BEEN PLACED AT AN ANGLE, AS PREVIOUS MAUDE SEARCHES HAVE SHOWN THAT THIS WAS REPORTED IN 2017 ON IV TUBING THAT RESULTED IN LEAKAGES OF FLUID OUT OF THE PORT. PT CODE: 1816. DEVICE CODES: 2946, 1670. REF REPORT: MW5178696.