InjuryFKB
BUDGET MEDICAL - ICU MEDICAL
Received Jul 29, 2003 · Event occurred Jun 27, 2003
Report MW1029162 · MDR key 475473
Device
Generic name
T-connector Ped With Valve
Manufacturer
Budget MedicalModel number
*Catalog number
*
Lot number
*
Product problems
- Coagulation in Device or Device Ingredient
- Use of Device Problem
Patient
12 MO
- Unknown (for use when the patient's condition is not known)
Narrative
Description of Event or Problem
USED T-CONNECTOR FOR AN ARTERIAL LINE ON A PT. T-CONNECTOR WAS FOUND TO HAVE A CLOT FORMATION. FURTHER DISCUSSION WITH PHYSICIAN INDICATED THAT STAFF HAVE BEEN USING T-CONNECTOR IN THIS MANNER (AS AN ARTERIAL LINE CONNECTOR) WHEN NEITHER THE PACKAGING NOR THE MANUFACTURER HAD INDICATED NOT TO USE THE DEVICE IN THIS MANNER. PHYSICIAN IS AFRAID A LESS EXPERIENCED MD WILL NOT NOTICE THE CLOTTING AND FLUSH THE LINE INTO AN ARTERY, EMBOLIZING A CLOT, POTENTIALLY CAUSING STROKE AND FOR DEATH.