FDA Adverse Event Malfunction Summary report: N

GUARDIAN PICC

MDR report key: 2168389 · Received July 11, 2011

Report

Report Number
2168389
Event Type
Malfunction
Date Received
July 11, 2011
Date of Event
January 22, 2011
Report Date
July 11, 2011
Manufacturer
MARIAN MEDICAL, INC.
Product Code
LJS
Product Problem
Yes
Report Source
User Facility report
Reporter Location
SD, US

Narratives

Description of Event or Problem · 1

GUARDIAN PICC LINE BROKE BETWEEN THE BUTTERFLY SITE AND THE HUB. THE FAMILY HAD PLACED THE PATIENT BACK INTO THE CRIB WHEN THE EVENT OCCURRED. FAMILY CALLED RN TO BEDSIDE AS SHE USED HER HAND AS A TOURNIQUET AROUND THE INFANT'S LEG, AS SHE DID NOT KNOW IF THE LINE HAD MIGRATED OR NOT. ANOTHER RN AT THE BEDSIDE WAS ABLE TO FIND THE TIP OF THE CATHETER WHICH WAS REMOVED PER PROTOCOL USING A HEMOSTAT. PRESSURE WAS HELD TO THE SITE FOR FIVE MINUTES AND THEN THE SITE WAS CLEANED PER PROTOCOL. THE NNP WAS CALLED TO THE BEDSIDE STAT WHEN THE INCIDENT OCCURRED AND WAS ABLE TO CONFIRM THE ENTIRE LENGTH OF THE PICC HAD BEEN REMOVED PER MEASUREMENT. NO INJURY TO THE INFANT.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 GUARDIAN PICC CATHETER, PICC LJS MARIAN MEDICAL, INC. * *

Patients

Seq Age Sex Outcome Treatment
1 5 DAY OTHER