inforMED
MalfunctionFOS

UMBILI-CATH

Received Jul 19, 2019 · Event occurred Apr 15, 2019

Report 8806988 · MDR key 8806988

Device

Generic name

Catheter, Umbilical Artery

Catalog number

4273505

Lot number

1182062

Product problems

  • Break

Patient

1 DA

  • No Known Impact Or Consequence To Patient
  • No Known Impact Or Consequence To Patient

Narrative

Description of Event or Problem

EXTREMELY PREMATURE INFANT DELIVERED AT (B)(6), INTUBATED IN THE DELIVERY ROOM AND ADMITTED TO NICU. A 3.5FR DOUBLE-LUMEN UMBILICAL VENOUS CATHETER (UVC) WAS PLACED. FOLLOWING AN X-RAY TO DETERMINE APPROPRIATE PLACEMENT, THE NEONATAL NURSE PRACTITIONER (NNP) GAVE AN ORDER TO PULL THE UVC BACK 0.5CM. WHEN THE RN GENTLY PULLED BACK ON THE UVC, IT REPORTEDLY SNAPPED IN HALF. THE PORTION REMAINING IN THE INFANT WAS HELD UNTIL THE NNP COULD SUCCESSFULLY REMOVE IT. STAFF REPORTED THE CATHETER BROKE BELOW THE SUTURE LINE. INSERTION DISTANCE - 6. LINE WAS SECURED BY SUTURE. NICU MANAGER REPORTED THE BREAK WAS BELOW THE SUTURE LINE AND DIDN'T APPEAR TO BE CAUSED BY THE SUTURE.