Description of Event or Problem · 0
ON [REDACTED DATE] DURING AN EBUS (ENDOBRONCHIAL ULTRASOUND) WITH DR. THE 19 GAUGE SINGLE USE ASPIRATION NEEDLE THAT WAS USED MALFUNCTIONED. DURING AN EBUS, A DISPOSABLE DEVICE IS PLACED THROUGH THE CHANNEL OF THE EBUS SCOPE TO COLLECT TISSUE. THIS DEVICE HAS A NEEDLE THAT COMES OUT OF THE END OF IT TO COLLECT THE SAMPLE AND THEN RETRACTS BACK IN WHEN NOT IN USE. AFTER DOING THE FIRST PASS OF TISSUE COLLECTING, THE DEVICE WAS WALKED OVER TO THE PATHOLOGY STATION SET UP IN THE ROOM. TO PUT THE SPECIMEN ONTO THE SLIDE APPROPRIATELY, THE NEEDLE NEEDS TO BE EXPOSED AND THEN A WIRE IS PASSED THROUGH TO PUSH OUT THE SPECIMEN. I TRIED SEVERAL TIMES TO EXPOSE THE NEEDLE, BUT THE NEEDLE WAS NOT COMING OUT THE END OF THE SHEATH. I ALERTED DR. THAT THERE WAS NO NEEDLE PRESENT AND THAT I HAD TRIPLE CHECKED IT. HE SWITCHED TO THE BRONCHOSCOPE TO MAKE SURE THERE WASN'T ANYTHING INSIDE THE PATIENT. HE DIDN'T FIND ANY PIECES OF THE DEVICE INSIDE THE PATIENT. IN AN EFFORT TO LOCATE THE NEEDLE AND BE CERTAIN IT WASN'T LEFT BEHIND, I CUT OPEN THE SHEATH OF THE DEVICE TO SEE IF IT HAD RETRACTED BACK INSIDE - WHICH IT HAD IN FACT DONE. THE NEEDLE WAS LOCATED WELL BEYOND WHERE IT SHOULD HAVE BEEN.