inforMED
InjuryHYC

GROCOTTS METHENAMINE SILVER STAIN

Received Nov 5, 2001 · Event occurred Jun 21, 2001

Report 359816 · MDR key 359816

Device

Generic name

Fast Green Stain Used To Process Cytology Specimens

Model number

*

Catalog number

S7440-8 (87008)

Lot number

1E31A

Product problems

  • Contamination

Patient

39 YR

  • Other (for use when an appropriate patient code cannot be identified)

Narrative

Description of Event or Problem

BRONCHIAL FLUID SENT TO CYTOLOGY WAS CONTAMINATED DURING PROCESSING WITH FUNGAL ELEMENTS. PT RESULTS WERE RELEASED: STATING "POSITIVE FOR FUNGUS". THE NEXT DAY, ANOTHER SPECIMEN HAD THE SAME FUNGAL ELEMENTS, THE SLIDES WERE COMPARED AND SIMILARITIES LEAD TO THE CONCLUSION THAT THIS WAS A CONTAMINANT. THROUGH THE NEXT SEVERAL WEEKS, A THOROUGH INVESTIGATION AS TO THE SOURCE OF THE CONTAMINANT WAS CONDUCTED. EVENTUALLY IT WAS DISCOVERED THAT A PURCHASED STAIN PRODUCT WAS BEING DELIVERED TO HOSPITAL ALREADY CONTAMINATED.