CSE TRAY MEDLINE

Description of Event or Problem

RN STATED THAT THEY FOUND THE YELLOW CLIP THAT GOES ON TOP OF EPIDURAL HAD FALLEN OFF, THEY NOTICED IT BEFORE IT LEAKED AND THEY CALLED MD AND MD REATTACHED AND BOLUSED THROUGH IT. CNM [CLINICAL NURSE MIDWIFE] STATED THAT THERE WAS DISCOORDINATION WITH PUSHING AFTER EPIDURAL BOLUS, BUT THAT 30 MINUTES INTO PUSHING AND PUTTING PATIENT ON HER SIDE THEY NOTICED THE EPIDURAL WAS AGAIN LEAKING DUE TO YELLOW CLIP FALLING OFF. MD STATED THAT YELLOW CLIPS FALLS OFF OFTEN AND IS NOT PREFERRED FOR THE CARE TEAM TO USE. RESULTED IN PATIENT NEEDING EPIDURAL REPLACED TWICE.