Description of Event or Problem · 0
INFORMATION SUPPLIED BY CUSTOMER: WHAT FAILED? LEAKAGE OR AIR INTAKE AT A PLUG THAT SHOULD NORMALLY BE OCCLUSIVE. HOW DID IT FAIL? DURING A PROCEDURE SEQUENCE OF EVENTS? PATIENT ARRIVING AT THE PULMONARY WARD FOR DRAINAGE OF PLEURAL EFFUSION. THE INTERN, ASSISTED BY THE PULMONOLOGIST, PERFORMS THE DRAINAGE PUNCTURE USING THE MEDICAL DEVICE USED IN THE DEPARTMENT, NAMELY AN 8FR CATHETER FROM ROCKET MEDICAL. THE PROCEDURE PROCEEDS NORMALLY, AND THE DRAIN IS IN PLACE IN THE PLEURA. AS DRAINAGE BEGINS, WE NOTICE A LEAK OR AIR INTAKE AT A PLUG THAT SHOULD NORMALLY BE OCCLUSIVE. THE DRAINAGE CONTINUED AND WAS COMPLETED WITHOUT CONSEQUENCE, BUT THERE COULD HAVE BEEN A PNEUMOTHORAX OR INCREASED PAIN FOR THE PATIENT. THE DOCTOR REMOVES THIS PLUG AND APPLIES HIS FINGER TO THE OPENING TO ENSURE IT IS SEALED (HYGIENE RULES ARE OBSERVED BY WEARING STERILE GLOVES). DRAINAGE CAN THEN CONTINUE SAFELY. IT IS A RECURRING PROBLEM WITH THE CATHETER DEVICE. THIS OCCURS ONCE OR SEVERAL TIMES A YEAR.