Description of Event or Problem · 1
24H PH PROBE PLACED. POST PLACEMENT CXR OBTAINED SHOWING INTACT PROBE IN ESOPHAGUS. MOTHER REPORTING PATIENT COMPLAINED OF THROAT PAIN THE EVENING OF PLACEMENT, AND THAT PATIENT PULLED PROBE OUT SHORTLY AFTER 12:30AM THE DAY IMMEDIATELY FOLLOWING PLACEMENT. NO RESTRAINTS IN PLACE. WHEN PROBE OUT, MOTHER NOTICED DISTAL TIP SEEMED SHARP. AS TECH RETRIEVED EQUIPMENT THAT MORNING, OBSERVED DISTAL TIP MISSING. PATIENT WITHOUT HEMATEMESIS OR ABDOMINAL PAIN. SERVICE INTERN AWARE OF SITUATION. FLOOR NURSING STAFF HAD ALREADY CONTACTED SERVICE FOR MD EVALUATION. READING FROM STUDY INDICATED PROBE SUCCESSFULLY RECORDING FOR APPROX. 10 HOURS BEFORE NO READING. MOTHER APPROVED INSERTION OF NEW PROBE THAT MORNING, AND INSERTION OCCURRED WITHOUT DIFFICULTY. SECOND PROBE WAS FROM SAME LOT NUMBER. REMAINING STOCK OF THAT LOT NUMBER SEQUESTERED.WHAT WAS THE ORIGINAL INTENDED PROCEDURE?PH MONITORING.DEVICE #1IS THIS A LABORATORY DEVICE OR LABORATORY TEST?NO.