The event involved a 4" (10 cm) appx 0.40 ml, smallbore trifuse ext set w/3 microclave® clear, 3 clamps, rotating luer where it was reported that when assessing a patient, iv hub tubing was disconnected from peripherally inserted central catheter (picc) line and in bed, the fluids stopped.The customer was told to flush through 5-10ml of iv infusing fluids (tpn/il) and reconnect.When they tried to reconnect, they noted the hub of the tri-fuse was rotating and loose.They then prepared another tri-fuse to replace it but the second tri-fuse was also rotating and loose.The event occurred at 13:30.There was patient involved but no patient harm reported.Additionally, the customer stated that it was determined that the reported issue was a result of education gap in their end.It was just the spinning collard that their team did not realize that they had to lock.This the second of two events.
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