BEUDAMED
    FDA Adverse Event Other Summary report: N

    BECTON DICKINSON 10 ML SYRINGE LUER-LOK TIP

    MDR report key: 1180447 · Received September 29, 2008

    Report

    Report Number
    MW5008474
    Event Type
    Other
    Date Received
    September 29, 2008
    Date of Event
    September 25, 2008
    Report Date
    September 29, 2008
    Manufacturer
    BECTON DICKINSON
    Product Code
    FMF
    Report Source
    Voluntary report
    Reporter Location
    CA, US
    Reporter Occupation
    PHARMACIST

    Narratives

    Description of Event or Problem · 1

    FLUID FOUND ON THE SYRINGE PUMP. SYRINGE OF DOPAMINE CHECKED AND FOUND TO HAVE SEVERAL ML OF AIR AND ONLY 2 ML OF DOPAMINE. THE DOPAMINE HAD BEEN STARTED AT 1600 AND HAD 8 ML OF DOPAMINE WHEN THE INFUSION WAS STARTED AT A RATE LESS THAN 0.5 ML/HR. UPON DISCOVERY THE NURSE CLAMPED THE LINE. AIR HAD INFUSED ONE THIRD OF THE LENGTH OF THE IV LINE MOVING TOWARDS THE PT. BLOOD PRESSURE HAD BEEN LOW SINCE THE START OF THE INFUSION WITH SEVERAL CHANGES IN DOSAGE POSSIBLY DUE TO THE SYRINGE LEAK. SYRINGE AND PUMP REMOVED FROM BEDSIDE. SYRINGE PUMP SENT TO BIOMEDICAL AND SYRINGE FOUND TO HAVE A LARGE CRACK ALONG THE SIDE. THE INPATIENT PHARMACY WAS NOTIFIED AS WAS THE BECTON DICKINSON REPRESENTATIVE. THE PHARMACY IDENTIFIED AND SEQUESTERED THE LOT NUMBER FROM WHERE THE SYRINGE WAS LIKELY TO HAVE COME. MOST OF THE SYRINGES WERE GIVEN TO THE BD REPRESENTATIVE FOR TESTING. PHARMACY, NURSING AND MATERIALS STAFF NOTIFIED OF THE CONCERN.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 BECTON DICKINSON 10 ML SYRINGE LUER-LOK TIP 10 ML SYRINGE FMF BECTON DICKINSON REF 309604 8151405

    Patients

    Seq Age Sex Outcome Treatment
    1 18 YR MEDFUSION PUMP 3500