Description of Event or Problem · 0
INFORMATION PROVIDED BY CUSTOMER: SEVERAL PULMONOLOGISTS PERFORMED THERAPEUTIC PLEURAL TAPS USING THE ROCKET MEDICAL DEVICE IN THE DEPARTMENT. IMMEDIATELY AFTER INSERTING THE CATHETER INTO THE PLEURAL SPACE AND REMOVING THE GUIDEWIRE, THE INTERFACE BROKE, PREVENTING THE PATIENT FROM ATTACHING THE DEVICE TO SEAL THE PUNCTURE. THE DRAINAGE CONTINUED AND ENDED WITHOUT CONSEQUENCE, BUT THE PATIENT COULD HAVE EXPERIENCED A PNEUMOTHORAX AND/OR RESPIRATORY FAILURE. THIS SITUATION OCCURRED THREE TIMES. THE PHYSICIAN APPLIED THEIR FINGER TO THE OPENING LEFT BY THE DEVICE'S BREAK TO ENSURE A SEAL (HYGIENE PROTOCOLS WERE FOLLOWED BY WEARING STERILE GLOVES). DRAINAGE CONTINUED, BUT UNDER LESS THAN OPTIMAL SAFETY CONDITIONS. ANOTHER PHYSICIAN CHOSE TO IMMEDIATELY REMOVE THE DEVICE AND REPLACE IT WITH ANOTHER, CAUSING ADDITIONAL PAIN FOR THE PATIENT. CHECK WITH THE TECHNICIAN AGAIN, AS THIS IS A RECURRING PROBLEM WITH THIS DEVICE. IT HAPPENS ONCE OR SEVERAL TIMES A MONTH. IT AFFECTS ONE OR MORE PATIENTS.