Description of Event or Problem · 0
INTERVENTIONAL CARDIOLOGIST WAS PERFORMING A PFO (PATENT FORAMEN OVALE) CLOSURE AND HAD A WIRE WITH A DIAGNOSTIC CATHETER IN THE LEFT ATRIUM. WHEN PROCEEDING TO DO A WIRE EXCHANGE OFF FLUOROSCOPY WITH LAB LIGHTS ON, IT WAS NOTED THAT THE STERILE FIELD WAS LITTERED WITH SMALL PLASTIC SHARDS THAT BROKE OFF FROM A 6 FRENCH CORDIS MPA DIAGNOSTIC CATHETER. THE FIELD OF CONTAMINATION INVOLVED THE ENTIRE STERILE FIELD UP TO THE SHEATH ENTERING THE BODY AS WELL AS THE PROVIDER'S HANDS. IN ADDITION, THE EQUIPMENT WAS REMOVED TO INCLUDE CATHETER, SHEATH, WIRE. GLOVES WERE EXCHANGED AND A NEW STERILE FIELD WAS CREATED ON TOP OF THE CONTAMINATED FIELD AFTER REMOVING AS MANY OF THE PARTICLES THAT COULD BE VISUALIZED. NO RETAINED PARTICLES ENTERED THE PATIENT; HAD IT ENTERED THE PATIENT, THE ENSUING RESULT WOULD HAVE BEEN STROKE AS EQUIPMENT WAS ALREADY ACTIVELY IN THE LEFT ATRIUM. THE TEAM CONTINUED THE CASE SINCE THEY WERE IN THE MIDDLE OF A CRITICAL PART OF THE PROCEDURE. THE DEFECTIVE 6 FRENCH CORDIS MPA LOT NUMBER IS 18102461. PATIENT WAS ADMITTED TO CCU (CRITICAL CARE UNIT) FOR OVERNIGHT OBSERVATION RATHER THAN PLAN DISCHARGE TO HOME. ON (B)(6) 2024, PATIENT WAS DISCHARGED HOME WITH NO ADVERSE OUTCOME.