Description of Event or Problem · 1
THE 3M CUROS / 70% IPA CAPS THAT ARE USED TO CAP PICC LINE HUB WAS DEFECTIVE. WHEN THE RN WENT TO DRAW BLOOD FROM THE PICC LINE FOR LAB DRAW, THE DOUBLE LUMEN RED PORT THAT WAS COVERED WITH THE CUROS CAP WAS EASILY REMOVABLE WITHOUT APPARENT DEFECT AND IT ALLOWED SALINE TO BE EASILY FLUSHED INTO THE PICC LINE, BUT WHEN DRAWING BACK TO WASTE AND DRAW BLOOD, THE BLOOD WAS COMING OUT FROTHY WITH AIR BUBBLES. THE NURSE WAS TROUBLESHOOTING THE SYSTEM AND REPEATEDLY ON EACH DRAWBACK, APPROX THREE ATTEMPTS THE SYRINGE WAS FILLING WITH BLOODY AIR BUBBLES. THE NURSE EXPELLED THE AIR BUBBLES INTO THE TRASH CAN TO PREVENT THE AIR BUBBLES FROM INADVERTENTLY GOING INTO THE PICC LINE. THE CUROS 3M GREEN CAP WAS FOUND TO HAVE BROKEN AND A THIN RIM OF GREEN WAS SEEN ON THE PICC LINE RED PORT ACCESS THAT WAS BEING USED FOR THE DRAW. ONCE THE THIN GREEN BROKEN PIECE OF THE CUROS 3M CAP WAS REMOVED, THE PICC LINE WAS ABLE TO DRAW BLOOD WITHOUT AIR BUBBLES. IT WAS VERY UNEXPECTED AND POTENTIALLY DANGEROUS FOR THE PICC LINE TO NOT BE OPERATING PROPERLY BECAUSE OF THE CUROS CAP BEING DEFECTIVE AND BREAKING, LEAVING A THIN RIM THAT PREVENTED AN AIR TIGHT SEAL THAT CAUSED AIR BUBBLING WHEN DRAWING BACK. THIS PROBLEM MAY NOT HAVE BEEN EASILY IDENTIFIED BY ANOTHER NURSE AND IT COULD HAVE RESULTED IN SERIOUS AND LIFE THREATENING ACCIDENT IF AIR HAD BEEN INJECTED INTO A PICC LINE. THIS DEFECT HAS NEVER BEEN WITNESSED BY THIS NURSE OR ANY OTHER NURSES THAT WERE WORKING THAT DAY. FDA SAFETY REPORT ID# (B)(4).