Description of Event or Problem · 1
PT HAD A 46 HOUR AMBULATORY "SMART" PUMP WITH FLUOROURACIL INFUSION. ATTACHED ON (B)(6) 2019 VIA RIGHT CHEST PORT. PT CALLED IN THE MORNING ON (B)(6) STATING THAT THE PUMP WAS LEAKING. PT PRESENTED TO OFFICE THIS MORNING WITH MALFUNCTIONING CHEMO "SMART" PUMP. HUBER NEEDLE WAS SECURE AND IN PLACE WITH STERILE DRESSING AND BIOPATCH BUT TUBING FROM HUMBER NEEDLE TO BLUE CLAVE ADAPTER WAS FULL OF BLOOD. CONNECTION SITE FROM CLAVE TO SMART PUMP TUBING WAS SECURED WITH TAPE BUT WAS LEAKING BLOOD AND 5FU CHEMOTHERAPY. PT HAD DRIED 5FU (IN THE FORM OF POWDER) ON HER ABDOMEN AND FANNY PACK. ALL CLAMPS WERE OPEN. CLAMPS WERE THEN CLOSED AND PUMP DISCONNECTED FROM BLUE CLAVE ADAPTER. IT WAS THEN NOTED THAT THE MALE ADAPTER FROM THE SMART PUMP TUBING WAS BROKEN OFF INSIDE THE CLAVE ADAPTER. PORT ACCESS WAS REMOVED WITHOUT FLUSHING AND ALL LINES AND PUMP WERE SECURED IN BIOHAZARD BAG. PT'S SKIN AND SURROUNDING AREA WAS WASHED WITH NS AND GAUZE. PORT WAS RE-ACCESSED UNDER STERILE TECHNIQUE, FLUSHED WITHOUT RESISTANCE AND HAS A GOOD BLOOD RETURN. MD NOTIFIED OF INCIDENT. PT IS REFUSING A NEW PUMP AT THIS TIME. PT REPORTED SIDE EFFECTS OF BLURRED VISION STARTING YESTERDAY EVENING - TO THE POINT THAT SHE WAS AFRAID SHE WAS GOING BLIND. PT STATES THAT HER VISION IS BETTER THIS MORNING - BUT DOES NOT WANT THE PUMP AGAIN TODAY. MD NOTIFIED OF ALL PTS CONCERNS AND OF THE PT'S REFUSAL TO RECEIVE REMAIN MEDICATION. NO NEW ORDERS RECEIVED.