inforMED
InjuryFKB

TRIMLINE

Received May 25, 2005 · Event occurred Apr 20, 2005

Report MW1035531 · MDR key 742619

Device

Generic name

9204 Adapter - Single Tube Male Bayonet To Dual Tube Male Lu

Model number

*

Catalog number

9204

Lot number

*

Product problems

  • Use of Device Problem

Patient

35 YR

  • Unknown (for use when the patient's condition is not known)

Narrative

Description of Event or Problem

THE PT WAS CONNECTED TO A PHILIPS MONITOR, WHICH INCLUDES EKG, RR, SPO2, AND NIBP. THE PT TOOK THE NIBP HOSE AND CONNECTED THIS TO HIS IV TUBING AT THE CLAVE CONNECTION BY UTILIZING THE DUAL TUBE ADAPTER APPLIED TO THE CABLE. HAD THIS NOT BEEN DISCOVERED BEFORE THE MACHINE CYCLED, THE PT COULD HAVE SUSTAINED A FATAL AIR EMBOLUS. ORIGINALLY THESE ADAPTERS MADE AND SUPPLIED BY TRIMLINE. PART# 9204, ADAPTS SINGLE TUBE BAYONET TO DUAL TUBE MALE -PUSH-LUER, SO THAT THE FACILITY COULD UTILIZE JUST ONE TYPE OF DISPOSABLE CUFFS WITH ALL OF OUR MAKES AND MODELS OF NIBP PRODUCTS. WE HAVE CHANGED OUT OUR DISPOSABLE CUFFS FOR THOSE WITH BAYONET FOR SINGLE TUBE APPLICATIONS ONLY, REMOVED AND DESTROYED ALL DUAL ADAPTERS.