Description of Event or Problem · 1
PATIENT'S TUBE FEEDING WAS CONNECTED IN ERROR TO GROSHONG CENTRAL VENOUS CATHETER INSTEAD OF J-TUBE. THE PATIENT RECEIVED TUBE FEEDING FOR APPROXIMATELY TWENTY MINUTES VIA GROSHONG CATHETER. THE PATIENT BEGAN MOANING LOUDLY, BECAME UNRESPONSIVE, A CODE BLUE WAS INITIATED WHICH TIME THE ERROR WAS DISCOVERED. THE CODE WAS UNSUCCESSFUL AND THE PATIENT WAS DISCOVERED, THE TUBE FEEDING WAS DISCONNECTED FROM THE GROSHONG AND IV FLUIDS WERE SUBSEQUENTLY INFUSED. THE EVENT OCCURRED DUE TO USER ERRORINVALID DATA - REGARDING SINGLE USE LABELING OF DEVICE. 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 NOT USED AS LABELED/INDENDED.DEVICE WAS EVALUATED AFTER THE EVENT. METHOD OF EVALUATION: VISUAL EXAMINATION. RESULTS OF EVALUATION: INCORRECT TECHNIQUE/PROCEDURE. CONCLUSION: USER ERROR CAUSED EVENT. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: INVALID DATA. CORRECTIVE ACTIONS: DEVICE DISCARDED, OTHER. THE DEVICE WAS NOT DESTROYED/DISPOSED OF.