Description of Event or Problem · 1
THE FACILITY WAS CONTACTED FOR ADDITIONAL DETAIL ON THIS EVENT. IN SPEAKING WITH THE REPORTER OF THE EVENT THE FOLLOWING INFO WAS RECEIVED. THE PT WAS ADMITTED TO THE HOSP AND RECEIVED 2 UNITS OF BLOOD, HOWEVER, THIS PT DOES HAVE GI RELATED ISSUES AND HAS RECEIVED BLOOD IN THE PAST DUE TO GI MEDICAL RELATED ISSUES. ADDITIONALLY, IT WAS LEARNED THAT THE DIALYSIS TECH HAD JUST REVERSED THE LINES PRIOR TO THIS INCIDENT. THE RN BELIEVES THE LUER CONNECTOR OF THE BLOODLINE THAT CONNECTS TO THE LUER OF THE CATHETER WAS "NOT TOTALLY TWISTED." ADDITIONAL INFO FROM UF REPORT: USER ERROR: NURSE DOING MACHINE CHECKS AND HEARD PT MAKING LOUD SNORING SOUNDS. NURSE LOOKED AT PT AND NOTICE PT TONGUE TO SIDE OF MOUTH. NURSE CALLED PT NAME AND WHEN NO RESPONSE, SHOOK PT'S ARM, STILL NO RESPONSE FROM PT. NURSE NOTED BLOOD AROUND CATHETER PORTS. VENOUS LINE CONNECTED TO CATHETER PORT AND HEMOSAFE CONNECTOR IN PLACE. A 300 TO 500 CC BLOOD NOTED ON FLOOR. NINE/ONE/ONE CALLED. VENOUS LINE AND CATHETER PORT LUER LOCK CONNECTIONS TIGHTEN AND BLOOD RETURNED WITH ADDITIONAL 300 ML N/S. PT REGAINED CONSCIOUSNESS AND ABLE TO ANSWER QUESTIONS APPROPRIATELY PRIOR TO 911 STAFF ARRIVAL. ADDITIONAL 500 CC BLOOD NOTED TO PT CLOTHING AND DOWN SIDE OF CHAIR WHEN PT TRANSFERRED FROM CHAIR TO STRETCHER BY 911 STAFF. PT TRANSFERRED TO HOSP BY 911 STAFF. PT ALERT, ANSWERING QUESTIONS APPROPRIATELY, VITAL SIGNS STABLE AT TIME OF TRANSFER TO HOSP.