Description of Event or Problem · 1
NURSE WAS ACCESSING THE PATIENT'S PORT-A-CATH, WHICH HAD BEEN ACCESSED BY THE SAME NURSE SEVERAL DAYS EARLIER WITHOUT INCIDENT. DURING ATTEMPT TO ACCESS, THE PATIENT GRIMACED AND MADE A HISSING NOISE. IT WOULD NOT FLUSH OR DRAW, SO THE NEEDLE WAS WITHDRAWN A SMALL DISTANCE. IT FLUSHED, BUT STILL WOULD NOT DRAW. THE PORT WAS DE-ACCESSED. THE NURSE RAN HER FINGER ALONG THE EDGE OF THE NEEDLE AND IT WAS ROUGH INSTEAD OF SMOOTH. NURSE STATES IT FELT LIKE THERE WAS A BURR ON THE EDGE THAT WAS ON THE REVERSE OF THE BEVELED SIDE. A NEW NEEDLE WAS OBTAINED AND THE PORT WAS ACCESSED WITHOUT INCIDENT. THERE WAS NO KNOWN HARM TO THE PATIENT. THERE ARE TWO LOT # PROVIDED BECAUSE NURSE IS NOT SURE FROM WHICH ONE THE NEEDLE WAS PULLED. 2ND LOT # 3854215, EXPIRATION DATE: 08/16/2024.