Description of Event or Problem · 1
THE BREATHING CIRCUIT WAS CHECKED PRIOR TO ANESTHESIA AND WAS PATENT. THE PATIENT WAS INTUBATED WITH FIBROPTIC SCOPE AND AFTER CONNECTION OF THE BREATHING CIRCUIT NO BREATH SOUNDS WERE HEARD. WITH MASK VENTILATION AND ENDOTUBE STILL IN PLACE SA02 ROSE FROM 50 TO 96. MASK VENTILATION WAS DIFFICULT. ETIDAL C02 SHOWED SMALL WAVES AND WAS RECALIBRATED, ANECTINE GIVEN; PATIENT REINTUBATED UNDER DIRECT VISION WITH LARGER #8 ET - NO VENT. MOUTH - ENDOTUBE; EMERGENT TRACH DONE. ET TUBE IN PLACE. AMBUBAG USED WITH INCREASE IN SA02 TO 100%. CIRCUIT RECHECKED, SMALL PIECE OF PLASTIC FROM FACE MASK BLOWN OUT OF PALL FILTER APPARENTLY FROM WRAPPER OF DISPOSABLE FACE MASK, BUT EXACT PIECE OF PLASTIC NOT FOUND. IT WAS OBSERVED TO COME OUT BY CRNADEVICE LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: SATISFACTORY CONDITION. THERE WAS NOT MULTIPLE PATIENT INVOLVEMENT.INVALID DATA - ON DEVICE SERVICE/MAINTENANCE. NO DATA - REGARDING DATE LAST SERVICED. SERVICE PROVIDED BY: INVALID DATA. INVALID DATA - SERVICE RECORDS AVAILABILITY. NO IMMINENT HAZARD TO PUBLIC HEALTH CLAIMED. DEVICE USED AS LABELED/INTENDED.DEVICE WAS EVALUATED AFTER THE EVENT. METHOD OF EVALUATION: ACTUAL DEVICE INVOLVED IN INCIDENT WAS EVALUATED, VISUAL EXAMINATION. RESULTS OF EVALUATION: STORAGE/SHIPMENT, OTHER. CONCLUSION: OTHER. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: MAYBE. CORRECTIVE ACTIONS: DEVICE USE CONTINUED WITH RESTRICTIONS/LIMITATIONS. THE DEVICE WAS DESTROYED/DISPOSED OF.