C.R. BARD, INC. (BASD) -3006260740 3FR SL PROVENA MIDLINE MAX BARRIER KIT; MIDLINE CATHETER
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Model Number N/A |
Device Problem
Material Frayed (1262)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 06/01/2023 |
Event Type
malfunction
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Event Description
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It was reported by customer that while attempting to remove the guidewire through the needle, the guidewire became lodged within the vessel.The nurse was able to remove the needle and guidewire altogether, however the guidewire appears to have unraveled approximately 15-20 cm from the tip.Additional information received (b)(6)2023: while attempting to place a midline catheter, the nurse attempted to remove the guidewire through the needle and the guidewire became lodged within the vessel.The nurse was able to remove the guidewire with the needle at the same time, however the guidewire appears to have unraveled approximately 15-20cm from the tip.The nurse stopped the procedure immediately and segregated the device.The physician was notified of the issue and an x-ray was ordered to check for any retained pieces of the device.The x-ray showed no evidence of a foreign body, and the patient required no other treatment related to the event.There was no adverse outcome for this patient.
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Manufacturer Narrative
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H11: section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.The device has not been returned to the manufacturer for evaluation.
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Event Description
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It was reported by customer that while attempting to remove the guidewire through the needle, the guidewire became lodged within the vessel.The nurse was able to remove the needle and guidewire altogether, however the guidewire appears to have unraveled approximately 15-20 cm from the tip.Additional information received 06/26/2023: while attempting to place a midline catheter, the nurse attempted to remove the guidewire through the needle and the guidewire became lodged within the vessel.The nurse was able to remove the guidewire with the needle at the same time, however the guidewire appears to have unraveled approximately 15-20cm from the tip.The nurse stopped the procedure immediately and segregated the device.The physician was notified of the issue and an x-ray was ordered to check for any retained pieces of the device.The x-ray showed no evidence of a foreign body, and the patient required no other treatment related to the event.There was no adverse outcome for this patient.
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Manufacturer Narrative
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H11: section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.Based on a review of applicable information, the following was concluded: the complaint of an unraveled guidewire was confirmed and the cause appeared to be associated with use.One 0.018¿ x 50cm flexura guidewire was provided for investigation.The core wire broke 3mm from the weld tip and the coil wire was stretched over the core wire.A piece of biological material was attached to the coil wire near the weld tip, which indicates that the guidewire was likely lodged within the needle with the biological material.It was reported that the guidewire became lodged within the vessel, which can occur if the guidewire is retracted through the needle.The instructions for use (ifu) caution, ¿if the guidewire must be withdrawn while the needle is inserted, remove both the needle and wire as a unit to prevent the needle from damaging or shearing the guidewire.¿ complaints received for this device and reported condition will continue to be tracked and trended.Information will be captured on trend reports and monitored as part of ongoing efforts to identify potential manufacturing related issues and emerging trends.
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