BEUDAMED
    FDA Adverse Event Injury Summary report: N

    PILLING WECK

    MDR report key: 240136 · Received September 14, 1999

    Report

    Report Number
    240136
    Event Type
    Injury
    Date Received
    September 14, 1999
    Date of Event
    September 9, 1999
    Report Date
    September 10, 1999
    Manufacturer
    PILLING WECK
    Product Code
    KCD
    Adverse Event
    Yes
    Report Source
    User Facility report
    Reporter Location
    TX, US
    Reporter Occupation
    NURSE

    Narratives

    Description of Event or Problem · 1

    DURING PROCEDURE A BOUGIE DILATOR (ESOPHAGUS) WAS TRANSECTED INSIDE THE STOMACH ALLOWING MERCURY FROM THE DILATOR TO ESCAPE. THE BOUGIE DILATOR WAS IMMEDIATELY REMOVED FROM THE PT'S BODY AND CONTAINED IN A PLASTIC BOWL WITH A LID. THE PEDIATRIC NURSE CLINICIAN WAS IMMEDIATELY ALERTED TO THE INCIDENT. PEDIATRIC NURSE CLINICIAN CALLED POISON CONTROL AND WAS TOLD TO SHOOT X-RAY. MERCURY LEVEL WAS DRAWN FROM THE PT AND AN X-RAY TAKEN. MERCURY NOTED IN THE X-RAY. NEW SUCTION CONTAINER WAS OBTAINED TO SUCTION MERCURY.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 PILLING WECK BOUGIE DIALATOR FR 24 KCD PILLING WECK FR 24 *

    Patients

    Seq Age Sex Outcome Treatment
    1 18 YR Required Intervention