Description of Event or Problem · 0
PATIENT WAS ADMITTED TO THE ED, AND A 20GA IV CATHETER WAS PLACED IN THE RIGHT FOREARM. THE PATIENT WAS, THEN, TRANSFERRED TO IMAGING TO RECEIVE A CT WITH CONTRAST, AND THE PREVIOUSLY PLACED 20GA IV CATHETER WAS CONNECTED TO THE CONTRAST INJECTOR. WHILE IN THE ED AND TWO HOURS AFTER THE INITIAL CT, THE PATIENT BEGAN TO DETERIORATE AND WAS BROUGHT BACK TO IMAGING FOR A HEAD CT WITHOUT CONTRAST. AN AIR EMBOLISM WAS CONFIRMED. PATIENT RETURNED TO ED, TWO ADDITIONAL IVS WERE PLACED (18GA-LEFT FOREARM AND 20GA-RIGHT ANTECUBITAL), DOCTOR INTUBATED THE PATIENT, AND THE PATIENT WAS LATER TRANSFERRED TO THE CRITICAL CARE UNIT (CCU) A FEW HOURS LATER. WHILE IN THE CCU, THE PATIENT RECEIVED A DOPPLER TO CONFIRM A DEEP VEIN THROMBOSIS (DVT) IN THE RIGHT ARM AND REPEAT CT SCANS WITHOUT CONTRAST OF THE HEAD. ADDITIONALLY, MEDICAL STAFF DISCOVERED A RIGHT TO LEFT SHUNT WHILE RECEIVING A ECHOCARDIOGRAM. PATIENT WAS EXTUBATED AND PLACED ON HIGH-FLOW OXYGEN BUT SHOWED SIGNS OF DEFICIT ON THE LEFT SIDE OF THE BODY. NEUROLOGY CONFIRMED A RIGHT-SIDED LARGE TERRITORY CEREBROVASCULAR ACCIDENT (CVA) DUE TO THE PRESENCE OF AN AIR EMBOLISM. PATIENT HAD NASOGASTRIC (NG) TUBES CONNECTED. THE REPORTING FACILITY HAS EXPERIENCED TWO ADDITIONAL ADVERSE EVENTS INVOLVING THE BD NEXIVA CLOSED IV CATHETER SYSTEM OF VARYING REFERENCE NUMBERS AND LOT NUMBERS. THE SPECIFIC LOT NUMBER IN EACH EVENT IS UNKNOWN. THE REPORTING FACILITY WOULD LIKE THE MANUFACTURER TO EVALUATE THE BD NEXIVA DIFFUSICS CLOSED IV CATHETER SYSTEM FOR POTENTIAL QUALITY ISSUES THAT MAY CONTRIBUTE TO SIMILAR EVENTS IN THE FUTURE.