Description of Event or Problem · 1
WHILE GENTLY FLICKING THE IV TUBING TO CLEAR THE LINE OF AIR (WHICH WAS CAUSING THE PUMP TO ALARM) THE TUBING BROKE AT THE POINT WHERE IT IS INSERTED INTO THE PUMP, CAUSING A COMPLETE BREAK IN THE INFUSION. LINE TO PATIENT WAS IMMEDIATELY CLAMPED OFF (WHICH WAS 'Y'-LINED INTO TPN TUBING) AND DEFECTIVE TUBING WAS REMOVED AND PRESENTED TO NURSE MANAGER. NO HARM TO THE PATIENT AND CENTRAL LINE WAS NOTED. NURSE MANAGER FOLLOWED UP WITH RN AND THIS IS NOT THE FIRST TIME THIS HAS HAPPENED. MULTIPLE EVENTS WITH PUMP BEEPING "AIR IN LINE" AND WHEN THE RN TOOK THE TUBING OUT OF THE PUMP TO FLICK THE TINY MICROSCOPIC AIR BUBBLES, THE TUBING BROKE. IT BROKE APART AT EITHER THE END OF THE RUBBER PART OF THE TUBING THAT ENTERS OR EXITS THE IV CHAMBER. WE HAVE NOT SEEN THIS ON SYRINGE PUMP TUBING BUT THAT PARTICULAR TUBING IS THE SAME TYPE FROM END TO END. ALL OF THE INCIDENTS HAVE INVOLVED THE PART OF THE TUBING THAT IS CONTAINED INSIDE THE PUMP.THIS OCCURRED TWICE WITH SAME PATIENT AND TWO DIFFERENT TUBING SETS, HOWEVER SAME PRODUCT, DIFFERENT LOT NUMBERS. PATIENT DID NOT EXPERIENCE HARM.DEVICE #1IS THIS A LABORATORY DEVICE OR LABORATORY TEST?NO.DEVICE #2IS THIS A LABORATORY DEVICE OR LABORATORY TEST?NO.