Description of Event or Problem · 1
PATIENT DIAGNOSED AS ACUTE RENAL FAILURE, OBSTRUCTIVE UROPATHY, PNEUMONIA AND SEVERE CONFUSION. PATIENT HAD BEEN RECEIVING NASO-GASTRIC TUBE FEEDING BUT HAD REMOVED HIS TUBE. A NEW NASO-GASTRIC TUBE (ENTRIFLEX) WAS REINSERTED BY THE PHYSICIAN, VERIFICATION OF TUBE PLACEMENT DONE BY PHYSSSICIAN BY INJECTING AIR INTO THE TUBE AND NOTING GURGLING SOUNDS IN STOMACH, IN ADDITION A PORTABLE CHEST X-RAY WAS ORDERED TO CHECK TUBE PLACEMENT. HOWEVER, TUBE FEEDING WAS STARTED BY PRIVATE DUTY NURSE BEFORE THE CHEST X-RAY WAS DONE. THE PATIENT EXPIRED DUE TO RESPIRATORY ARREST. CHEST X-RAY REVEALED LOCATION OF NG TUBE AS IN THE RIGHT LUNG AND FLUID IN LOBESDEVICE LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: CRITICAL 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: NONE OR UNKNOWN. RESULTS OF EVALUATION: INHERENT RISK OF PROCEDURE. CONCLUSION: THERE WAS NO DEVICE FAILURE, OTHER. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: YES. CORRECTIVE ACTIONS: DEVICE DISCARDED, OTHER. THE DEVICE WAS DESTROYED/DISPOSED OF.