A user facility nurse reported that at the beginning of the patient¿s hemodialysis (hd) treatment, a blood leak occurred between the venous end of the combiset and the connection to the patient¿s fistula.Per the nurse, the leak was due to a loose connection and that the connection was not separated.The connection was retightened and the patient successfully completed treatment on the same machine with the same supplies.There was no patient injury, adverse events, or medical intervention required as a result of the event.The patient¿s estimated blood loss (ebl) was 100 ml.The lot number of the combiset was unknown.Additionally, the needle used with the fistula was a non-fresenius device.Manufacturer information for the needle was unable to be provided.The combiset was discarded after treatment and is not available to be returned to the manufacturer for physical evaluation.
|