Description of Event or Problem · 0
PATIENT'S SPOUSE REPORTED THAT CURLIN 6000¿ PUMP TUBING, NON-FILTERED MANUFACTURED BY MOOG (140-4114) USED FOR ADMINISTRATION OF IV HYDRATION ON (B)(6) 2023 WAS COMPROMISED. THERE WAS A HOLE IN THE PART THAT COMES OUT OF THE YELLOW REGULATOR END, AND THE PATIENT AND SPOUSE WERE CONCERNED ABOUT POSSIBLE CONTAMINATION OF IV ACCESS (PORT) SINCE NOT A CLOSED SYSTEM. SPOUSE CALLED ON (B)(6) 2023 AND SPOKE TO RN ON CALL. SPOUSE TOOK PATIENT TO (B)(6) HOSPITAL ED ON (B)(6) 2023, DUE TO PT COMPLAINING OF TACHYCARDIA. PATIENT RECEIVED IV HYDRATION AND BLOOD CULTURES WERE DRAWN, AFTER WHICH PATIENT WAS DISCHARGED TO HOME. ON (B)(6) 2023, BLOOD CULTURE RESULTS CAME BACK POSITIVE FOR METHICILLIN-RESISTANT STAPH EPIDERMIS ((B)(6) 2023 SAMPLES). PATIENT ADVISED TO GO TO (B)(6) HOSPITAL ED AND PATIENT WAS SUBSEQUENTLY ADMITTED TO (B)(6) HOSPITAL FOR TREATMENT WITH IV VANCOMYCIN X 10 DAYS. ALL SUBSEQUENT BLOOD CULTURES WERE NEGATIVE. FROM THE ON-CALL LOG ON (B)(6) 2023: ON CALL NURSE CALLED PATIENT AT 1006 WITH A 14MIN CONVERSATION. PER SPOUSE (PCG) AFTER APPROX 3 1/2HRS INTO THE TIMED INFUSION IT WAS NOTICED THAT THERE WAS IV FLUID ON THE FLOOR AND THE FANNY PACK WHICH HOLDS THE CURLIN PUMP AND LITER OF NS WAS ALSO SOAKED. IT WAS DISCOVERED THERE WAS AN APPARENT LEAK IN THE PUMP TUBING WHERE THE FLEXIBLE SECTION OF TUBING THAT THEN CONNECTS TO FIRMER TUBING WHICH EXITS THE LEFT SIDE OF THE CURLIN PUMP. PER PCG THEY NOTICED A STEADY STREAM OF NS COMING OUT OF THIS EXPOSED AREA OF TUBING WITH THE FORCED RATE SET VIA CURLIN PUMP. THEY DID STOP THE INFUSION AND DISCONNECTED THAT TUBING FROM END CAP CONNECTED TO HUBER NEEDLE. PCG CONCERNED AND HAD QUESTIONS REGARDING POSSIBLE SIGNS OF SEPSIS SINCE THIS INFUSION ULTIMATELY WAS NOT A CLOSED DELIVERY SYSTEM. SN INFORMED PCG/PATIENT TO WATCH FOR SIGNS OF INFECTION AT PORT SITE SUCH AS REDNESS, SWELLING, DRAINAGE FROM ACCESS SITE, OR WARM TO TOUCH IN THIS AREA OF PORT PLACEMENT. ALSO, TO ASSESS SYMPTOMS OF PATIENT'S OVERALL WELL-BEING AND IF PATIENT BEGINS TO SPIKE A FEVER. INSTRUCTED ON MAKING SURE WITH LOADING OF PUMP TUBING THAT NO AREAS OF THE TUBING ARE POTENTIALLY PINCHED WHICH MAY CAUSE AN AREA OF OPENING/WEAKNESS WITHIN THAT TUBING. INSTRUCTED TO CALL MD (B)(6) 2023 WITH ANY ADDITIONAL QUESTIONS/CONCERNS, AND CLEARLY IF PATIENT IS SHOWING ANY SIGNS/SYMPTOMS OF POSSIBLE INFECTION TO GO TO THE ER. PATIENT IS SEEN WEEKLY BY CM NURSE FOR PORT ACCESS AND PATIENT RECEIVES 4 LITERS OF NS OVER A 7-DAY TIMEFRAME. PATIENT DE-ACCESSES OWN PORT ON MONDAYS, AND IUHH SN THEN TYPICALLY SEES THE PATIENT ON MONDAYS AS WELL FOR NEW HUBER NEEDLE PLACEMENT. PCG AND PATIENT VOICED UNDERSTANDING WITH ABOVE COMMUNICATION AND WILL FOLLOW-UP AS NEEDED. NO FURTHER QUESTIONS OR CONCERNS VOICED BY PCG/PATIENT AND INSTRUCTED TO CALL STATEWIDE TRIAGE FOR ANY OTHER PROBLEMS THROUGHOUT THE NIGHT.