Description of Event or Problem · 1
AS THE NURSE CUT THE SUTURE HOLDING THE PATIENT'S A-LINE IN PLACE HE NOTED PULSATING BLOOD AT THE RIGHT RADIAL ARTERY SITE. AS THE A-LINE CATHETER WS REMOVED IT WAS OBSERVED TO BE SHORTER THAN USUAL. AN X-RAY OF THE PATIENT'S RIGHT HAND REVEALED A RETAINED PORTION OF CATHETER. A 11/2" PIECE OF CATHETER WAS REMOVED SURGICALLY. THE PATIENT IS IN STABLE CONDITIONDEVICE 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: NONE OR UNKNOWN, OTHER, OTHER. CONCLUSION: THERE WAS NO DEVICE FAILURE, USER ERROR CAUSED EVENT. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: YES. CORRECTIVE ACTIONS: USER EDUCATION PROVIDED, OTHER. INVALID DATA - ON DEVICE DESTROYED/DISPOSED OF STATUS.