CURE MEDICAL CATHETER INSERTION KIT
Report
- Report Number
- 3005471919-2019-00016
- Event Type
- Injury
- Date Received
- March 2, 2019
- Date of Event
- December 31, 2018
- Report Date
- March 1, 2019
- Manufacturer
- CURE MEDICAL LLC
- Product Code
- OHR
- UDI-DI
- 00815947020468
- Adverse Event
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- FL, US
- Reporter Occupation
- 003
Narratives
THE USER'S TECHNIQUE WAS REVIEWED AND IT WAS FOUND THAT HE WAS HANDLING AN ALCOHOL PREP PAD (MANUFACTURED BY (B)(4)) THAT IS NOT PART OF THE STERILE INSERTION KIT. THE USER WAS USING THE BZK SWAB SUPPLIED WITH THE KIT AND THE ALCOHOL PREP PAD TO WIPE DOWN THE GLOVES. THE RECOMMENDED TECHNIQUE DOES NOT CALL FOR USING A SEPARATE ALCOHOL PREP PAD. THE BZK SWAB SUPPLIED IN THE STERILE INSERTION KIT IS MEANT TO BE USED TO CLEAN THE URETHRAL OPENING AND NOT THE GLOVES. IT IS UNCLEAR WHY THE USER WAS USING THE ALTERNATE TECHNIQUE AND HE WAS ADVISED TO DISCUSS HIS CATHETERIZATION TECHNIQUE WITH HIS DOCTOR AS IT APPEARS TO DEVIATE FROM ACCEPTED CLINICAL PRACTICE. HANDLING OF THE ALCOHOL PREP PAD (PACKAGING IS NOT STERILE) DURING THE INSERTION PROCESS MAY LEAD TO CONTAMINATION OF THE GLOVES WHICH ARE LATER USED TO INSERT THE CATHETER. THIS REPORT IS MADE FOR THE INSERTION KIT AND A SEPARATE REPORT IS MADE FOR THE CATHETER SINCE IT CANNOT BE DETERMINED THE EXTENT TO WHICH EITHER DEVICE MAY HAVE CAUSED OR CONTRIBUTED TO THE ADVERSE EVENT.
ROUTINE INTERMITTENT CATHETER PATIENT (USER) ACQUIRED A UTI WHILE CONCURRENTLY USING BOTH A CURE MEDICAL BRAND INTERMITTENT CATHETER AND CATHETER INSERTION KIT (GLOVES, BZK WIPE, COLLECTION BAG, UNDERPAD, LUBRICATING JELLY). NO SPECIFIC PROBLEMS WERE REPORTED WITH THE CATHETER OR INSERTION KIT BUT THE USER STATED HE HAD DIFFICULTY INSERTING THE CATHETER. THE USER ALSO REPORTED HE WAS NOT FOLLOWING THE RECOMMENDED TECHNIQUE WHICH MAY INTRODUCE CONTAMINATION THAT COULD CAUSE OR CONTRIBUTE TO AN INFECTION.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 177822 | CURE MEDICAL CATHETER INSERTION KIT | CATHETER CARE TRAY | OHR | CURE MEDICAL LLC | K1 | 17B15702 | 00815947020468 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 73 YR | Other |