Description of Event or Problem · 1
PINK TINGED EFFLUENT NOTED IN EFFLUENT BAG IMMEDIATELY UPON TREATMENT INITIATION. PAGE SENT TO FELLOW, TEAM CARING FOR PATIENT (PT) TODAY WAS UNAWARE OF ANY PREVIOUS EVENTS RESULTING IN QUESTIONABLE BLOOD LEAK. FELLOW DISCUSSED WITH ATTENDING AND DECIDED WE SHOULD TERMINATE TREATMENT. CARTRIDGE WAS SAVED TO BE SENT TO MANUFACTURER FOR FURTHER INVESTIGATION. UPON FURTHER DISCUSSION WITH AQUAPHERESIS REP., THIS WAS AN ISSUE THOUGHT TO HAVE HAPPENED ON WEDNESDAY. NO NOTES/ ICARES RELAYED TO THE TEAM REGARDING THIS ISSUE. SEVERAL HD (HEMODIALYSIS) NURSES WERE "WATCHING" THIS PATIENT DUE TO SHORT STAFFING. IMPROVED COMMUNICATION REGARDING HAND OFF AND EVENTS. PER DIALYSIS NURSE, PINK TINGED IN EFFLUENT BAG RIGHT AFTER INITIATION. PCM (PATIENT CARE MANAGER) WERE NOT AWARE THAT THIS HAPPENED LAST WEEK WITH THE SAME ISSUE. UNSURE RATHER IT WAS THE SAME LOT # AS IT WAS ALREADY DISCARDED. SALES REP. FOR AQUADEX WAS NOTIFIED OF THE ISSUE. CARTRIDGE WAS SAVED FOR FURTHER INVESTIGATION. NEPHROLOGY FELLOW AND ATTENDING WERE NOTIFIED AND AGREED TO RE-START A NEW SET-UP WITH BLOOD PRIME. PCM TO DISCUSS THIS IN HUDDLES OF BETTER COMMUNICATIONS TO PROVIDE BETTER CARE AND QUALITY TO OUR PATIENTS. PCM SPOKE TO MEDICAL DIRECTOR. SHE BELIEVED IT IS HEMOLYSIS FROM THE PATIENT AND NOT THE MACHINE OR THE CARTRIDGE. WE WILL START WITH A SLOW BFR (BLOOD FLOW RATE) AND GRADUALLY INCREASE TO PRESCRIBED BFR, PERHAPS THIS WILL HELP. DISCUSSED THE PLAN WITH THE TEAM TO IMPLEMENT AND TRACK IF IT HELPS. THERE WAS NO HARM IN THIS EVENT.