Description of Event or Problem · 1
SUBCUTANEOUS INFUSION PORT INSERTED INTO THE RIGHT SUBCLAVIAN VEIN SEPTEMBER, 1991. PORT INFECTED AND PATIENT TAKEN TO OR FOR REMOVAL FEBRUARY 19, 1992. PATIENT GIVEN IV SEDATION. FLUOROSCOPY DONE TO VISUALIZE CAHTETER PRIOR TO REMOVAL. CATHETER VISUALIZED IN RIGHT ATRIUM. DYE INJECTED TO SEE HOW MUCH OF CATHETER LEFT IN SUBCLAVIAN VEIN. PORT REMAINED IN PLACE BUT THE ENTIRE CATHETER HAD SHEARED OFF AND WAS CONTAINED IN THE RIGHT ATRIUM. PATIENT TAKEN TO RADIOLOGY FOR REMOVAL. RADIOLOGY USED A SNARE TO SUCCESSFULLY RETREIVE THE CATHETER FROM THE RIGHT ATRIUM. MFG. WAS CALLED AFTER THE EVENT. DEVICE HAS BEEN KEPT IN THE RISK MANAGEMENT OFFICEDEVICE 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: OTHER. CONCLUSION: NONE OR UNKNOWN. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: UNKNOWN (CANNOT DETERMINE). CORRECTIVE ACTIONS: OTHER. INVALID DATA - ON DEVICE DESTROYED/DISPOSED OF STATUS.