Description of Event or Problem · 1
DURING THE INSERTION OF A RIGHT SUBCLAVIAN PERMA-CATH DIALYSIS CATHETER, A J WIRE (GUIDEWIRE) WAS INSERTED INTO THE SUPERIOR VENA CAVA. THE DILATOR & SHEATH WERE PASSED OVER THE J WIRE WITH SOME DIFFICULTIES ENCOUNTERED, REQUIRING REMOVAL OF THE J WIRE AND REINSERTION OF THE NEEDLE OVER THE CUTOFF PORTION OF THE J WIRE. A NEW J WIRE WAS INSERTED & REAPPLICATION OF DILATOR & SHEATH WAS ACHEIVED. THE INSERTION OF THE PERMA-CATH CATHETER WAS COMPLETED BUT UPON REMOVAL OF THE J-WIRE SIGNIFICANT RESISTANCE WAS ENCOUNTERED. X-RAY REVEALED GOOD POSITION OF THE PERMA-CATH CATHETER BUT A PORTION OF THE J WIRE WAS LODGED IN THE SUPERIOR VENA CAVA AND EXTENDED INTO THE JUGULAR VEIN. PATIENT WAS TRANSFERRED TO OHSU/INTERVENTIONAL RADIOLOGY SAME DAY FOR SUCCESSFUL RETRIEVAL OF J WIRE IN TOTAL. RETURNED TO AGH SAME DAYDEVICE LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: FAIR 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, OTHER, OTHER, INVALID DATA. RESULTS OF EVALUATION: UNANTICIPATED SHORT TERM COMPLICATION OF PROCEDURE. CONCLUSION: THERE WAS NO DEVICE FAILURE. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: NO. CORRECTIVE ACTIONS: DEVICE DISCARDED, OTHER. THE DEVICE WAS DESTROYED/DISPOSED OF.