STERILE HIGH PRESSURE ANGIOGRAPHIC SYRINGES FOR SINGLE USE

Description of Event or Problem

PATIENT RECEIVING MRI CONTRAST VIA POWER INJECTION USING STANDARD IV INJECTION KIT. FOLLOWING CONTRAST INJECTION NOTED THAT THE CONTRAST WAS NOT ADMINISTERED AND THE PATIENTS BLOOD FLOWED BACKWARDS THROUGH THE CIRCUIT VIA A SMALL SPLIT AT THE DISTAL END OF THE TUBING PROVIDED WITH THE INJECTOR KIT JUST PROXIMAL TO THE HUB WHICH CONNECTS TO THE PATIENTS IV TUBING.