DeathDYN
SALIVA EJECTOR
Received Jul 5, 1995 · Event occurred Jun 25, 1995
Report 23622 · MDR key 23622
Device
Product problems
- Design/structure problem
- Misplacement
Patient
32 YR
- Death
- Respiratory Distress
Narrative
Description of Event or Problem
ON 6/16/95, THIS PT RECEIVED A TRACHEOSTOMY FOR VENTILATORY DEPENDENCE AND CHRONIC-ASPIRATION. AFTER THE SURGERY, THE NURSES WERE USING THE SALIVA EJECTOR TO SUCTION SECRETIONS AROUND THE TRACHEOSTOMY. ON 6/25/95, THE PT WAS FOUND IN FULL CARDIAC ARREST. AT THE BEGINNING OF THE CODE, IT WAS NOTED THAT THE SALIVA EJECTOR WAS STUCK INSIDE THE OPENING OF THE TRACHEOSTOMY AND WAS COMPLETELY OCCLUDING THE AIRWAY. THE PT EXPIRED AT 0056 ON 6/25/95. IT APPEARED TO THE UNTRAINED EYE THAT THE EJECTOR BELONGED IN THE TRACHEOSTOMY DUE TO IT'S DESIGN, COLOR AND FIT.