BEUDAMED
    FDA Adverse Event Death Summary report: N

    CORFLO FEEDING TUBE WITH CORTRAK 2 ENTERAL ACCESS SYSTEM

    MDR report key: 4377124 · Received December 30, 2014

    Report

    Report Number
    4377124
    Event Type
    Death
    Date Received
    December 30, 2014
    Date of Event
    December 27, 2014
    Report Date
    December 30, 2014
    Manufacturer
    CORPAK MEDSYSTEMS, INC
    Product Code
    KNT
    Adverse Event
    Yes
    Report Source
    User Facility report
    Reporter Location
    VA, US
    Reporter Occupation
    NURSE

    Narratives

    Description of Event or Problem · 1

    RN WAS ADMINISTERING MEDICATIONS (PHENYTOIN 100 MG ORAL SUSPENSION AND DILTIAZEM 30 MG TABLET). BOTH MEDS WERE ORDERED TO BE ADMINISTERED VIA CORFLO FEEDING TUBE (CORTRAK 2 ENTERAL ACCESS SYSTEM). DECADRON IV ALSO GIVEN AT THE SAME TIME. THE CARDIZEM AND DILANTIN WERE PLACED IN A 60 ML LUER LOCK SYRINGE. THESE TWO PO MEDICATIONS WERE GIVEN THROUGH THE IV INADVERTENTLY. THE ERROR WAS IMMEDIATELY SEEN AND THE RN TRIED TO WITHDRAW THE MEDICATIONS FROM THE IV. THE PATIENT BECAME UNRESPONSIVE. RAPID RESPONSE WAS CALLED. PT BECAME PULSELESS (IV ATROPINE AND EPI GIVEN). PT WAS A DNI, DAUGHTER REQUESTED THAT RESUSCITATION BE STOPPED. PT EXPIRED.THIS EVENT IS BEING REPORTED DUE TO THE LIKELIHOOD OF CONFUSION OF USING LUER LOCK SYRINGES INTENDED FOR PO MEDS WITH CORFLO/CORTRAK AND INADVERTENTLY GIVING THE PO MEDS VIA THE IV ROUTE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    859825 CORFLO FEEDING TUBE WITH CORTRAK 2 ENTERAL ACCESS SYSTEM TUBES, GASTROINTESTINAL (AND ACCESSORIES) KNT CORPAK MEDSYSTEMS, INC * 69407

    Patients

    Seq Age Sex Outcome Treatment
    1 87 YR Death