Pt presented for routinely scheduled hemodialysis treatment.Pretreatment vital signs were; weight (b)(6) kg, bp 159 / 77, pulse 84 respirations 16, temperature 97.7.Treatment initiated at 0627 at a blood rate of 400 ml/min via a central venous catheter.Pt was routinely monitored approximately every thirty minutes with no issues reported.At 0824, the hand of the patient was near the blood line and central venous catheter connection site.After the patient was asked move his hand, it was noted the venous blood line was disconnected from the venous lumen of the central venous catheter.The previously attached hemaclip was not attached to the central venous catheter or blood line.The central venous catheter lumen and blood line were immediately clamped.An estimated 400 800 mls of blood were lost.Pt lost consciousness and pulse and resuscitative measures ensued.Pulse was regained while the patient was in the facility.Ems transported the patient to the local emergency department were resuscitative measures were again administered, but were unsuccessful leading to the expiration of the patient.
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