inforMED
MalfunctionLKB

CUROS

Received Jan 3, 2020 · Event occurred Nov 27, 2019

Report 9543678 · MDR key 9543678

Device

Generic name

Pad, Alcohol, Device Disinfectant

Manufacturer

3m Company

Catalog number

CFF10-250

Product problems

  • Break
  • Entrapment of Device

Patient

26280 DA

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

Narrative

Description of Event or Problem

PATIENT WITH PICC LINE HAD GREEN, DISINFECTING END CAP OVER PICC LINE NEEDLELESS CONNECTOR, PER STANDARD. WHEN RN ATTEMPTED TO REMOVED/UNSCREW THE GREEN, DISINFECTING END CAP, IT BROKE INTO TWO PIECES AND PART OF THE GREEN, DISINFECTING END CAP WAS STUCK/REMAINED ON THE PICC LINE NEEDLELESS CONNECTOR. RN WAS UNABLE TO GET THE PIECE OF THE GREEN, DISINFECTING END CAP OFF AND THE PICC LINE NEEDLELESS CONNECTOR HAD TO BE CHANGED BY THE VASCULAR ACCESS TEAM RN.

Description of Event or Problem

PATIENT WITH PICC LINE HAD GREEN, DISINFECTING END CAP OVER PICC LINE NEEDLELESS CONNECTOR, PER STANDARD. WHEN RN ATTEMPTED TO REMOVED/UNSCREW THE GREEN, DISINFECTING END CAP, IT BROKE INTO TWO PIECES AND PART OF THE GREEN, DISINFECTING END CAP WAS STUCK/REMAINED ON THE PICC LINE NEEDLELESS CONNECTOR. RN WAS UNABLE TO GET THE PIECE OF THE GREEN, DISINFECTING END CAP OFF AND THE PICC LINE NEEDLELESS CONNECTOR HAD TO BE CHANGED BY THE VASCULAR ACCESS TEAM RN.