Description of Event or Problem · 1
NO PTS WERE HARMED IN THIS EVENT. ON THREE DIFFERENT INSTANCES (INVOLVING 3 DIFFERENT PTS) A BEDSIDE ENDOSCOPIC PROCEDURE WAS PERFORMED. DATES WERE (B)(6) 2011. ALL PTS WERE EXPERIENCING A GI BLEED. ON (B)(6) 2011: DURING AN UPPER ENDOSCOPY EXAM, THE PHYSICIAN PRESSED THE LIGHT SAVE BUTTON ON THE LIGHT SOURCE SECONDS AFTER INTUBATING THE PT WITH THE ENDOSCOPE WHEN BLOOD WAS SEEN. THE PT WAS HAVING AN UPPER GI BLEED AROUND HIS NEWLY-IMPLANTED PEG TUBE. THE PT WAS TREATED WITH ARGON PLASMA COAGULATION AT THE BLEEDING SOURCE. AT THE CONCLUSION OF THE EXAM, THE PHYSICIAN EXPERIENCED DECREASED VISUALIZATION, INCLUDING VERY LOW LIGHT LEVELS AS WELL AS AN "ECLIPSE-LIKE" OBSCURITY IN THE CENTER OF THE VISUAL FIELD. THE PHYSICIAN ATTEMPTED TO CLEAR THE OBSCURITY IN THE VISUAL FIELD BY WIPING THE TIP OF THE ENDOSCOPE ON THE GASTRIC MUCOSA, W/O SUCCESS. THE ENDOSCOPE WAS WITHDRAWN. UPON INSPECTION OF THE TIP OF THE SCOPE, THERE WAS A PINKISH/BROWN HUE COVERING THE LIGHT GUIDES OF THE SCOPE. AFTER WIPING THE TIP OF THE SCOPE WITH GAUZE, ENDOSCOPIC PICTURES WERE TAKEN OF A WHITE TOWEL, WHICH REVEALED A PINKISH/BROWN HAZE IN THE VISUAL FIELD (PRESUMABLY BLOOD THAT HAD COAGULATED OVER THE LIGHT GUIDES). THERE WAS NO IMPACT TO PT CARE AS A RESULT OF THIS INCIDENT. OTHER EVENTS ON (B)(6) 2011: MIDWAY THROUGH THE EXAM, THE PHYSICIANS NOTED THAT THE IMAGE ON THE SCREEN WAS YELLOW AND VISUALIZATION OF THE STOMACH WAS DIMINISHED. THE ENDOSCOPE WAS REMOVED AND IT WAS NOTED THAT THE LIGHTS AT THE TIP OF THE SCOPE WERE YELLOW. THE RN OBTAINED A NEW ENDOSCOPE AND THE EXAM WAS RESUMED. THE RN INFORMED THE PHYSICIANS THAT THE LIGHT SAVE BUTTON ON THE LIGHT SOURCE WAS NOT PUSHED FOR THE FIRST EXAM (INTENDED TO REDUCE ADHERENCE OF BLOOD TO TIP OF ENDOSCOPE), AND PROCEEDED TO PUSH THE LIGHT SAVE BUTTON FOR THE SECOND PHASE OF THE EXAM. MIDWAY THROUGH THE SECOND PHASE OF THE EXAM, A "VAPOR-LIKE" HAZY APPEARANCE WAS EVIDENT ON THE ENDOSCOPIC IMAGE. THE PT'S VARIX WAS INJECTED WITH EPINEPHRINE AND CLIPPED AND THE ENDOSCOPE WAS WITHDRAWN. THE PT WAS NOT HARMED. ON (B)(6) 2011: SHORTLY AFTER THE ENDOSCOPE WAS PLACED IN THE PT'S STOMACH, THE PHYSICIAN NOTED "VAPOR-LIKE" HAZY APPEARANCE ON THE ENDOSCOPIC IMAGE. THE ENDOSCOPE WAS WITHDRAWN AND PRE-CLEANED AT THE BEDSIDE AND RETURNED TO THE GI LAB REPROCESSING AREA. ANOTHER ENDOSCOPE WAS OBTAINED AND A NEW LIGHT SOURCE AND VIDEO PROCESSOR CART WAS ALSO OBTAINED AND TAKEN TO THE BEDSIDE. THE EXAM WAS RESUMED WITH THIS ENDOSCOPE. BLOOD CLOTS WERE SEEN IN THE PT'S STOMACH, AND SEVERAL ATTEMPTS WERE MADE TO REMOVE THE CLOTS. DURING THE EXAM, THE PHYSICIAN AGAIN NOTED A SIMILAR "VAPOR-LIKE", HAZY APPEARANCE ON THE ENDOSCOPIC IMAGE. THE PHYSICIAN CONCLUDED THAT THERE WAS NO IMMEDIATE NEED FOR TREATMENT BASED ON WHAT WAS SEEN, AND THE ENDOSCOPE WAS WITHDRAWN. (B)(4).