Description of Event or Problem · 1
DIALY-NATE SET W/ LUER CONNECTIONS USED FOR MANUAL PERITONEAL DIALYSIS: FOUND DRAIN VOLUME ERRORS WHILE USING SET ON PATIENT. UNABLE DECREASE WEIGHT DESPITE 1122ML UF VIA PERITONEAL DIALYSIS (PD), FOUND DRAIN VOL ERRORS SO PATIENT TEMPORARILY SWITCHED TO AQUADEX ON AND MANUAL PD STOPPED. PATIENT WITH BILATERAL RENAL AGENESIS WHO IS DIALYSIS DEPENDENT ON MANUAL PD USING DIALY-NATE SET W/ LUER CONNECTIONS. PATIENT GOAL IS TO SLOWLY INCREASE PD FILL VOLUME TO GOAL OF 120ML PRIOR TO TRANSITION TO PD CYCLER. PATIENT WAS ON 90ML TO 110ML DURING THIS OCCURRENCE. PD DEXTROSE AND FREQUENCY OF CYCLES IS ADJUSTED TO ACHIEVE PROPER UF AND MAINTAIN FLUID BALANCE, WEIGHT, BP/HR, & LABS. MANUAL PD WAS INITIATED AT 40ML AT A RATE OF ~10ML DAILY AND AQUADEX WAS DISCONTINUED 5 DAYS LATER. PATIENT'S WEIGHT INCREASED DRAMATICALLY WITH CHANGE OF +0.41KG. PREVIOUSLY (B)(6) AND WAS (B)(6). PD ORDERS WERE CHANGED FROM 1HR CYCLES TO 30MIN CYCLES BECAUSE OF LOW UF IN AM SHIFT. FOUND WEIGHT UNCHANGED DESPITE UF, SO I ASKED BEDSIDE RN TO WEIGH DRAIN VOLUME FOR 6 CYCLES, FOUND CONSISTENT ERROR OF +15ML WITH EACH CYCLE. WITH SAME DIALY-NATE SETUP, I MEASURED BURETROL VOLUME IN AND DRAINED STRAIGHT TO DRAIN CYLINDER AND WEIGHED VOLUMES, AND FOUND SAME ERROR OF +15ML DRAIN VOLUME, BURETROL FILL VOLUME WAS CORRECT, SO NO CONCERNS THAT VOLUME FILLED TO PATIENT WAS IN ERROR. STOPPED PD THAT AFTERNOON. I DID NOT SEQUESTER THAT DIALY-NATE SETUP UP (ALTHOUGH IT SHOULD HAVE BEEN) & LOT# WAS UNKNOWN. I REVIEWED ALL LOT#S OF DIALY-NATE SET SUPPLIES IN SUPPLY ROOM. I DID NOTICE THAT THE DRAIN CYLINDER ON LOT# 1210840 MFG 05-10-2021 TO HAVE A DIFFERENT FONT PRINT. TESTED BY WEIGHT 2 SETS WITH THIS LOT # AND FOUND BURETROL VOLUME IN WAS CORRECT BUT DRAIN VOLUME HAD ERROR OF +10ML ON ONE SET AND +20ML ON ANOTHER SET. I LOOKED BACK IN SCOPE COLLABORATIVE LIST SERVE BECAUSE I RECALLED ANOTHER HOSPITAL ASKING IF ANY OTHER HOSPITAL FOUND DRAIN VOLUME ERRORS, ANOTHER HOSPITAL QUOTED LOT# 1210425 WAS GIVING THEM ERRORS. I PULLED ALL DIALY-NATE SETS WITH LOT# 1210840 MFG 05-10-2021 & LOT# 1210425. NOTIFY MEDICAL TEAM/NURSES RE: CONCERNS WITH DIALY-NATE PD TUBING. NOTIFIED CENTRAL SUPPLY WHO IS PULLING THOSE LOT#S FROM THEIR SUPPLY. SENT PICTURE OF DRAIN CYLINDER DIFFERENCE BETWEEN LOT# WITH DRAIN ERROR AND LOT#S WITH CORRECT DRAIN VOLUMES. ALSO, SENT EMAIL RECOMMENDED OF THE FOLLOWING TO ALL RNS: IF YOU ARE UNSURE THAT A DIALY-NATE SET OF A DIFFERENT LOT# MAY HAVE DRAIN VOLUME ERRORS, I RECOMMEND THE FOLLOWING: PRIOR TO USING SET ON PATIENT, TEST SET BY: FILL BURETROL WITH 100ML, DRAIN OUT TO DRAIN CYLINDER AND ASSESS VOLUME, THEN WEIGHT VOLUME. IF CONCERNED WITH DRAIN VOLUME, WEIGHT ALL DRAIN VOLUMES AND RECORD THIS IN EPIC INSTEAD OF VOLUME ON DRAIN GRADUATED CYLINDER. CONTACTED UTAH MEDICAL PRODUCT VENDOR WHO PROVIDES DIALY-NATE SET: WAITING FOR REPLY. THERE WAS MINIMAL TEMPORARY HARM IN THIS EVENT.