Description of Event or Problem · 1
THE PATIENT WAS A 87 YEAR OLD MALE, ADMITTED ON 2/22/93 WHO HAD BRAIN CANCER COLON CANCER, R/O SEPSIS, PNEUMONIA. ON 2/22/93, AT APPROXIMATELY 2200 1/2 STRENGTH ISOCAL FEEDING STARTED AT 50CC/HR VIA N/G TUBE. APPROX. 30 MINUTES LATER, IT WAS NOTED THAT 400CC INFUSED. MD CALLED. PATIENT LATER EXPIRED ON 2/23/93 AT 9:40 PM. THE CAUSE OF DEATH LISTED WAS CARDIOPULMONARY ARREST, SECONDARY TO PNEUMONIA, SEPSIS. THE PATIENT WAS A DO NOT RESUSCIATEDEVICE NOT LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: CRITICAL CONDITION. THERE WAS NOT MULTIPLE PATIENT INVOLVEMENT.DEVICE SERVICED IN ACCORDANCE WITH SERVICE SCHEDULE. DATE LAST SERVICED: 01-DEC-92. SERVICE PROVIDED BY: USER FACILITY BIOMEDICAL/BIOENGINEERING DEPARTMENT. SERVICE RECORDS AVAILABLE.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, PERFORMANCE TESTS PERFORMED. RESULTS OF EVALUATION: COMPONENT FAILURE, NONE OR UNKNOWN. CONCLUSION: NONE OR UNKNOWN. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: INVALID DATA. CORRECTIVE ACTIONS: DEVICE PERMANENTLY REMOVED FROM SERVICE. INVALID DATA - ON DEVICE DESTROYED/DISPOSED OF STATUS.