Description of Event or Problem · 0
WE HAVE BEEN EXPERIENCING ISSUES WITH THE CENTRAL LINE CAPS FOR THE PAST 6 MONTHS. THERE HAS BEEN NO PATIENT HARM IN ANY OF THE 18 REPORTED EVENTS BELOW. EVENT #1: RN WAS NOTIFIED BY MANAGER THAT THERE IS A POTENTIAL MALFUNCTION WITH THE CAPS ON PICC LINES WITH THEM POTENTIALLY BEING CRACKED AND TOLD TO CHECK CAPS TO SEE IF THEY HAVE ANY VISIBLE CRACK, BACK UP OF BLOOD IN CAP OR MOISTURE ENCLOSED. THIS PATIENT WAS FOUND TO HAVE BLOOD BACKED UP IN CAP WITH DROPLETS INSIDE POSSIBLY INDICATING ENCLOSED MOISTURE. THE RN FOR THIS PATIENT WAS NOTIFIED AND WE WERE TOLD TO DO A CAP CHANGE, WHICH WAS THEN COMPLETED. THE CAP WAS THEN SAVED AND PLACED IN A BIO HAZARD BAG. EVENT #2: CAP LEAKING AT SITE (RED PORT PICC RIGHT ARM), NOTED BY OFF-GOING RN, CENTRAL VENOUS PRESSURE (CVP) FLUID ORDERED. SAQ CHANGED CAP, TUBING, AND CVP FLUID FIRST THING THIS AM. NO PRODUCT AVAILABLE FOR RETURN. EVENT #3: CAP ON WHITE PORT OF RIGHT FEMORAL CENTRAL VENOUS LINE (CVL) FOUND TO BE CRACKED. UNABLE TO RETRIEVE LOT NUMBER FOR CAP AS IT HAD NOT BEEN RECORDED. CAP LAST CHANGED ON EVENT #4: TRANSDUCER AND PRIMARY TUBING CONNECTED TO CAP WHEN FOUND TO BE CRACKED ALONG WITH MICROBORE TUBING AND A PALL FILTER CONNECTED FARTHER UP THE LINE FOR MEDICATION ADMINISTRATION. NEITHER LUMEN DRAWING SO TPA ORDERED. CAP AND LINES CHANGED TO REPLACE CRACKED CAP. EVENT #5: AT THE END OF PT'S HYDROCORTISONE INFUSION, I WENT TO CLEAN HUB AND ATTACH A FLUSH TO HIS MICRO-BORE TUBING AND FOUND THAT TUBING WAS WET. WHEN I ATTEMPTED TO FLUSH, PART OF FLUSH WENT INTO TUBING AND PART OF FLUSH LEAKED OUT OF THE CAP AND ONTO THE FLOOR. UPON INSPECTION OF FLOOR, AREA UNDER PUMP NOTED TO BE WET. IT APPEARS THE CAP WAS BROKEN SOMEHOW ALLOWING FOR MEDICATION TO LEAK OUT. NO PRODUCT AVAILABLE FOR RETURN. EVENT #6: AFTER A BLOOD TRANSFUSION, THE BLUE PORT OF THE RA LINE BECAME OCCLUDED AND UNABLE TO FLUSH FROM STOPCOCK. RN DISCONNECTED TUBING AND FLUSHED FROM CAP, THE LINE WAS ABLE TO FLUSH BUT REQUIRED SOME FORCE AND IN DOING SO THE CAP BROKE INTERNALLY. (B)(6) HAS THE PRODUCT IN HER OFFICE. EVENT #7: PT RETURNED FROM MRI. PICC LINE ALARMING OCCLUDED. LINE FLUSHED AT CAP WITH DIFFICULTY AND BLOOD RETURN NOTED. CVP FLUID AND MED LINE ATTACHED TO CAP. WHEN DOING A LINEN CHANGE MED WAS NOTED TO BE INFUSING INTO THE BED AT THE CAP CONNECTION. PICC LINE WAS CLAMPED. FLUID NOTED INSIDE CAP. CAP AND TUBING CHANGED. NO PRODUCT AVAILABLE FOR RETURN. EVENT #8: FOUND CAP CRACKED WHEN RE-ASSESSING HIGHER CVP AND TRACING LINE. CAP CONNECTED TO PRESSURE BAG AND TRANSDUCER INTO WHITE LUMEN. (B)(6) HAS THE PRODUCT IN HER OFFICE. EVENT #9: CAP ON SWAN CVL FROM OR. PRESSURE LINE INFUSING AT 3 ML/HR AND NOTED TO BE LEAKING AT THE CAP. APPEARS TO BE DRIPPING AROUND SUCTION DEVICE INSIDE THE CAP. CAP REMOVED AND NEW CAP PLACED. EVENT #10: AT CHANGE OF SHIFT, NOTICED CAP CRACKED ON PORT OF PICC THAT WAS BEING TRANSDUCED. IMMEDIATELY CHANGED CAP AND TUBING. CVL FLUID THE ONLY FLUID RUNNING THROUGH CAP AT THAT TIME. NO PRODUCT AVAILABLE FOR RETURN. EVENT #11: CRACKED CAP FOUND ON AM ASSESSMENT OF UMBILICAL VENOUS CATHETER (UVC). CONDENSATION AND BLOOD IN CAP. CAP WAS ATTACHED TO CVP TUBING. (B)(6) HAS THE PRODUCT IN HER OFFICE. EVENT #12: PER REPORTER CENTRAL LINE CAP NOTED TO BE FILLED WITH BLOODY FLUID. CAP ASSUMED TO BE CRACKED. NO BLOOD NOTED OUTSIDE OF IV TUBING OR ON THE LINENS IT WAS STUCK WHEN TRYING TO UNSCREW IT. NO PRODUCT AVAILABLE FOR RETURN.