Summary of MedSun Reports Describing Adverse Events With IV Catheters
MedSun: Newsletter #45, February 2010

Intravenous (IV) catheters are common medical devices that are used for fluid and/or medication administration in the treatment of patients in all age groups. About 25 million Americans have intravenous catheters placed each year. IV catheters are placed in the veins of the upper or lower extremities, the larger veins of the neck, or the upper chest near the collar bone using a rigid, metal needle. The needle is removed and the plastic catheter, or cannula, remains in the vein. [1]

Over the past 2 years, MedSun has received 76 adverse event reports associated with the IV Catheter. The reports represent 6 manufacturers: Becton Dickinson (58), Smith Medical (9), B. Braun Medical, Inc. (6), Cook, Inc. (1), C.R. Bard, Inc. (1), and Unomedical A/S (1). The reports were submitted by 48 hospitals between July 2007 and July 2009. The most frequently reported device problems, in descending order of frequency, were:

• Needle did not retract properly
• Leak
• Piece broke off
• Insecure connection
• Tip broke off
• Hole in tubing
• Device component broke off
• Missing parts
• Needle bent

No reports involved a patient death. The patient injuries listed below were reported in 35 of these 76 reports.
• Needed to be re-stuck (17)
• Piece left, needed to be removed without surgery (6)
• Piece left, needed surgery to remove (4)
• Piece left in patient that was not removed (3)
• Nurse stuck by needle (3)
• Hematoma (2)

Of the reports that listed patient age, 11 had a patient age listed as less than 21 years and 35 had a patient age listed as greater than 21 years. Of the reports that listed patient gender, a total of 30 reports involved female patients and a total of 20 reports involved male patients.

These MedSun reports contributed to FDA awareness of the device problems. FDA currently has this issue under review.


Adverse Events
DeviceDevice identifiers (model , catalog number, lot) Event Description
B. Braun medical/introcan safety 24 g x 3/4" None/none/none IV CATHETER REMOVED FROM HAND OF BABY AFTER IV INFILTRATED. AT REMOVAL, CATHETER TIP NOTED TO BE NOT INTACT. TIP WAS APPROXIMATELY HALF THE NORMAL LENGTH, TIP ANGLED, SMOOTH. X-RAY AND ULTRASOUND OF HAND DID NOT SHOW A RETAINED FOREIGN BODY.
Smiths medical md/acuvance plus None/3350/37h235e03 NUCLEAR MEDICINE TECHNICIAN WAS REPOSITIONING THE ANGIOCATH AND THE CATHETER TIP SHEARED OFF. THE TECHNOLOGIST THINKS PART OF THE CATHETER BROKE IN THE PATIENT'S ARM. WHEN THE CATHETER WAS PULLED OUT, IT LOOKED LIKE SOME OF THE PLASTIC FROM THE CATHETER WAS MISSING. THE PATIENT WAS RETURNED TO ULTRASOUND THE NEXT DAY, AND AT THIS TIME THE SUPERFICIAL VEIN WAS FOUND TO BE THROMBOSED.
Smiths medical md/protectiv plus safety iv catheter None/ref 3067/none LEFT HAND IV SITE NEAR THUMB CHECKED AFTER GIVING MEDICATION. SITE COVERED WITH DRESSING. DRESSING REMOVED. CATHETER SLIGHTLY OUT OF VEIN AT INSERTION SITE. CATHETER BROKEN OFF WITH FOLLOW-UP X-RAY SHOWING A 1.6CM TUBULAR RADIOPAQUE DENSITY ADJACENT TO THE FIRST CARPOMETACARPAL JOINT FOREIGN BODY. FOLLOW-UP SURGICAL PROCEDURE TO REMOVE THE FOREIGN BODY IDENTIFIED IT AS AN IV CATHETER.
Becton dickinson/insyte autoguard winged None/none/none END CONNECTOR WOULD NOT CONNECT TO SYRINGE OR IV TUBING. ADDITIONAL INFO. OBTAINED FROM THE SITE: NO PRODUCT NUMBER IS AVAILABLE BECAUSE THE PACKAGING FOR THE PRODUCT WAS ALREADY DISCARDED WHEN THE NURSE REPORTED IT. THE INFANT HAD TO BE RESTUCK. THERE WAS NO DAMAGED PART. THE END OF THE IV WHERE A SYRINGE OR IV TUBING ATTACHES WOULD NOT ALLOW FOR ANYTHING TO SCREW ON.
Smiths medical md/protectiv None/3048 /35e10se02 PATIENT HAD A 14 GAUGE IV CATHETER INSERTED IN THE ED. AFTER THE PATIENT ARRIVED IN THE UNIT, NURSING WAS PUSHING IV MEDICINES AND THE PATIENT COMPLAINED OF PAIN AND BURNING AT SITE. THE IV PUSH WAS IMMEDIATELY STOPPED AND THE SITE WAS INSPECTED. THE SITE APPEARED TO HAVE INFILTRATED. THE IV CATHETER WAS REMOVED AND IT WAS NOTICED THAT THE CATHETER HAD A CREASE AND A PIN POINT HOLE AT ONE EDGE. THE CATHETER HAD BEEN INSERTED IN THE BEND OF THE ELBOW AND IT IS BELIEVED THAT THE PATIENT BENT THEIR ELBOW BENDING THE CATHETER WHICH CAUSED THE CREASE. AFTER BENDING SEVERAL TIMES IT MADE A HOLE IN THE CATHETER.
Cook,/none None/c-utlmy-7013-rsc-abrm-hc-fst-r /1859855 THIS REPORT IS TO NOTIFY THE FDA OF LABELING CHANGES BY COOK ON THEIR 7 FR TRI-LUMEN CATHETERS, WHICH WE BELIEVE IS INTRODUCING THE POSSIBILITY OF A HUMAN ERROR AS THE ORIGINAL COLOR CODING IS BEING CHANGED BETWEEN THE DISTAL AND PROXIMAL CONNECTIONS OF THE CATHETER.
Becton dickinson infusion therapy systems/insyte autoguard None/none/8284277 RN WAS STARTING AN IV ON ED PATIENT WHEN THE IV CATHETER NEEDLE SEPARATED FROM THE PLASTIC HUB. THE NEEDLE WAS RETRIEVED INTACT WITHOUT HARM TO THE PATIENT.
Becton dickinson infusion therapy systems/bd insyte autoguard 18 ga 1.16 in, 1.3 x 30mm/ref 381444/7340858 NURSE WAS ATTEMPTING TO PLACE AN 18 GAUGE INTRAVENOUS CATHETER (IV START) INTO A LABOR & DELIVERY PATIENT'S VEIN IN LEFT FOREARM. NURSE ENTERED THE PATIENT'S VEIN WITH THE CATHETER AND WHEN ATTEMPTING TO ADVANCE THE CATHETER, THE HUB BROKE OFF FROM THE PLASTIC ANGIO. FORTUNATELY THE NURSE WAS ABLE TO REMOVE THE CATHETER. POTENTIAL FOR DETACHED CATHETER TO HAVE ENTERED PATIENT'S VEIN.
B. Braun medical/introcan iv None/none? 8c28258271 RN HAD A NEEDLESTICK AFTER PLACING AN 18 GAUGE IV CATHETER INTO A PATIENT. THE SAFETY ON THE CATHETER MALFUNCTIONED AND THE NEEDLE TIP WAS EXPOSED WHICH STUCK THE NURSE. MANUFACTURER RESPONSE FOR 18 GAUGE CATHETER, INTROCAN IV. CONTACTED BBRAUN REP ANDREA KU WHO RESPONDED THAT THEY WILL SEND INSTRUCTIONS REGARDING SHIPPING THE DEVICE AND SAMPLES FROM THE LOT # TO THIER QA DEPARTMENT.
Becton dickinson infusion therapy systems/angiocath 381523/none/none THE PATIENT HAD A PERIPHERAL IV IN THEIR LEFT ANTERIOR FOREARM. THEY RECEIVED A METHAMPHETAMINE INFUSION OVER A TWO MINUTE PERIOD. UPON COMPLETION OF THE METHAMPHETAMINE INFUSION, NORMAL SALINE BEGAN INFUSING AT 100 CC/HR. AT THIS TIME, THE PATIENT COMPLAINED OF SOME DISCOMFORT AT THE IV SITE. THE IV WAS STOPPED AFTER ONLY 5 CC HAD INFUSED AND THE PHYSICIAN WAS INFORMED. THE NURSE REMOVED THE CANNULA SHORTLY AFTERWARDS AND AT THIS TIME IT WAS NOTICED THAT THE CANNULA TIP WAS ONLY ABOUT 1/4 INCH LONG WHEN IT SHOULD HAVE BEEN ONE INCH LONG. AFTER PALPATING BELOW THE IV INSERTION SITE, THE REMAINDER OF THE CANNULA SITE WAS IDENTIFIED AND FOUND TO STILL BE IN THE PATIENT. THE PATIENT WAS MADE AWARE OF SITUATION AND ENCOURAGED TO REMAIN ON BED REST, AND A LOOSE TOURNIQUET WAS APPLIED TO THE UPPER ARM. EXCISION OF CATHETER FROM THE LEFT FOREARM WAS PERFORMED AT THE BEDSIDE UNDER ULTRASOUND GUIDANCE.
Becton dickinson infusion therapy systems/insyte autoguard winged shielded 20ga/none/none WHILE PLACING PERIPHERAL IV IN PATIENT'S ARM, NURSE CANNULATED THE VEIN WITH THE 20G ANGIOCATH. NURSE PRESSED THE BUTTON TO RETRACT THE NEEDLE AND LEAVE THE CATHETER IN THE VEIN. WHEN NURSE PULLED OUT THE NEEDLE, IT HAD ONLY HALF RETRACTED INTO THE SPRING MECHANISM AND WAS STICKING OUT AT AN ANGLE.
Becton dickinson infusion therapy systems/bd insyte autoguard None/381444/8284277 UPON ADVANCING CATHETER, SHEATH SEPARATED FROM GREEN PLASTIC HUB, SHEATH REMOVED INTACT. NO PATIENT HARM.
Becton dickinson/insyte autogaurd None/none/none THE NURSE WAS ATTEMPTING TO INSERT A 22 GAUGE CATHETER INTO THE RIGHT ANTECUBITAL AREA. WHEN SHE WENT TO PULL THE CATHETER OUT, SHE NOTICED THAT PART OF THE CATHETER WAS MISSING. IT SEEMED TO HAVE BROKEN OFF INSIDE THE PATIENT'S ARM. THE NURSE DENIED REINSERTING THE NEEDLE BACK IN THE CATHETER ONCE SHE PULLED IT OUT. THE EMERGENCY DEPARTMENT PHYSICIAN WAS IMMEDIATELY NOTIFIED.
Becton dickinson infusion therapy systems/bd insyte autoguard None/none/none IV CATHETER INSERTED WITHOUT PROBLEM, GOOD BLOOD FLUSH BACK, NORMAL SALINE FLUSH, WHILE FLUSHING HUB OF CATHETER CRACKED AND UNABLE TO USE. REMOVED AND RETAINED.
Smiths medical asd/18g 1-1/4"cathlon Cath iv 18g 1.75in radopqgrn/405420/07.01 535 RN STARTED 18 GAUGE IV AND HOOKED UP TUBING/FLUID. IV WAS LEAKING AT THE HUB. NEW IV STARTED WITH ANOTHER 18 GAUGE CATHETER WHICH ALSO LEAKED AT THE HUB. BOTH IVS DISCONTINUED AND A NEW IV WAS STARTED WITH A 16 GAUGE CATHETER. NO FURTHER LEAKAGE NOTED.
Becton dickinson infusion therapy systems/angiocath-n, autoguard None/381720/8009372 RN IN PEDIATRIC ICU REPORTED A PROBLEM WITH THE BD ANGIOCATH-N AUTOGUARD. STATED THAT WHEN SHE WAS ATTEMPTING TO RESTART IV, THE ANGIOCATH INSERTED AND THE SPRING WOULDN'T WORK AND NEEDLE WOULDN'T RETRACT. ALSO HAD DIFFICULTIES WITH THE ANGIOCATH "SPLITTING" AND THE TIP "SHREDDING".
Becton dickinson infusion therapy systems/bd insyte autoguard None/381423/none MED SURG TECH WAS DISCONTINUING INTRAVENOUS ACCESS RESEAL FROM PATIENTS RIGHT ARM, IT WAS NOTED THAT THE HUB WAS LYING ON TOP OF THE SKIN AND WAS NOT CONNECTED TO THE CLEAR CATHETER PIECE NORMALLY INSERTED INTO THE VEIN. TECH IMMEDIATELY NOTIFIED PRIMARY RN WHO ASSESSED THE PATIENT, AND SEARCHED THE DRESSING, BED LINENS AND ENTIRE PATIENT ROOM FOR MISSING CATHETER. DILIGENT EFFORTS TO FIND CATHETER PIECE BY NURSE WERE UNSUCCESSFUL. PRIMARY PHYSICIAN WAS NOTIFIED AND SOFT TISSUE X RAY ORDERED.
Becton dickinson infusion therapy systems/insyte autoguard None/381444/none SOFT TISSUE ULTRASOUND DONE AT ANOTHER FACILITY REVEALED 1.8CM X 0.25 CM TUBULAR STRUCTURE WITHIN THE SUBCUTANEOUS SOFT TISSUES ALONG THE ANTERIOR ASPECT OF THE LEFT DISTAL FOREARM MEDIALLY, SUSPICIOUS FOR FOREIGN OBJECT. THIS WAS THE SITE OF A PREVIOUS IV. REQUIRED OUTPATIENT REMOVAL UNDER LOCAL ANESTHESIA.
B. Braun medical/introcan safety None/4251644-02/9b12258302 THE SAFETY NEEDLE COVER WAS NOT PRESENT WHEN THE NEEDLE WAS REMOVED FROM THE ANGIOCATH AFTER INSERTION. NURSE EXAMINED CLOSELY FOR SIGNS OF THE CAP AND FOUND NONE. X-RAY TO PATIENT'S FOREARM REVEALED NO FOREIGN OBJECT FOUND.
Becton dickinson/insyte autoguard None/381434 /7324911 WHILE INSERTING THE IV, NURSE FELT SOME RESISTANCE AND REMOVED THE ANGIOCATH. IT WAS NOTICED THAT THE ANGIO TIP HAD SHEARED.
Becton dickinson/insyte autoguard None/381444 /7519078 THE IV CATHETER LEAKED WHEN FLUIDS/MEDICATIONS WERE PUSHED THROUGH. THE LEAK OCCURRED AT THE JOINT OF THE CATHETER AND THE GREEN PLASTIC. THE NURSE VERIFIED THAT THE MALE ADAPTER WAS TIGHT.
Becton dickinson infusion therapy systems/insyte autoguard None/none/7088198 THE NURSE WAS PREPARING TO START AN IV LINE ON A PATIENT. SHE OPENED THE IV CATHETER FROM THE PACKAGE AND GRASPED THE WHITE SHIELD TO REMOVE IT. HOWEVER, WHEN SHE TRIED TO REMOVE THE DEVICE, THE IV CATHETER AND THE HUB REMAINED INSIDE THE SHIELD. THE REMAINDER OF THE NEEDLE AND NEEDLE GUARD CAME OUT. STAFF RETRACTED THE NEEDLE AND DISPOSED OF IT IN THE SHARPS CONTAINER. WHEN EXAMINING THE WHITE SHIELD, IT APPEARED THAT THE HUB WAS CROOKED AND SHOVED UP AGAINST ONE WALL OF THE PACKAGING. STAFF OBTAINED ANOTHER IV CATHETER TO START THE IV LINE. THERE WAS NO HARM TO THE PATIENT OR STAFF AS A RESULT OF THIS EVENT.
Becton dickinson infusion therapy systems/insyte autoguard None/none/7088198 THE NURSE WAS PREPARING TO START AN IV LINE ON A PATIENT. SHE OPENED THE IV CATHETER FROM THE PACKAGE AND GRASPED THE WHITE SHIELD TO REMOVE IT. HOWEVER, WHEN SHE TRIED TO REMOVE THE DEVICE, THE IV CATHETER AND THE HUB REMAINED INSIDE THE SHIELD. THE REMAINDER OF THE NEEDLE AND NEEDLE GUARD CAME OUT. STAFF RETRACTED THE NEEDLE AND DISPOSED OF IT IN THE SHARPS CONTAINER. WHEN EXAMINING THE WHITE SHIELD, IT APPEARED THAT THE HUB WAS CROOKED AND SHOVED UP AGAINST ONE WALL OF THE PACKAGING. STAFF OBTAINED ANOTHER IV CATHETER TO START THE IV LINE. THERE WAS NO HARM TO THE PATIENT OR STAFF AS A RESULT OF THIS EVENT.
Becton dickinson infusion therapy systems/insyte autoguard None/none/7100852 THE NURSE WAS PREPARING TO START AN IV ON THE PATIENT. WHEN THE WHITE SHEATH FROM THE IV WAS REMOVED, THE NURSE NOTED THAT THE NEEDLE INSIDE THE CATHETER WAS BENT. SHE REMOVED THE HUB AND DISCARDED IT IN THE SHARPS CONTAINER. UPON VISUAL INSPECTION, THE NEEDLE WAS OBVIOUSLY BENT TO ONE SIDE. THE NEEDLE WAS RETRACTED INTO THE SAFETY SHEATH AND SAVED ALONG WITH THE PACKAGING. NO PATIENT OR STAFF MEMBERS WERE HARMED AS A RESULT OF THIS INCIDENT. PICTURES OF THE DEFECTIVE NEEDLE WERE TAKEN IN ADDITION TO THE SUBMISSION OF THIS REPORT.
Becton dickinson/insyte autoguard 20 gauge, 1.16 inches/none/8007782 THE NURSE WAS PREPARING TO START AN IV LINE. WHEN SHE OPENED THE 20 GAUGE, 1.16 INCHES INSYTE AUTOGUARD IV PACKAGE, SHE NOTED THAT THE NEEDLE HAD PIERCED THE IV CATHETER APPROXIMATELY 2MM FROM THE DISTAL END OF THE DEVICE. OF NOTE WAS THAT THE NEEDLE HAD NOT RETRACTED WHEN THE NURSE DISCOVERED THE PUNCTURE. ALL OTHER ELEMENTS OF THE IV CATHETER WERE INTACT, WHICH LEAD STAFF TO THE CONCLUSION THAT SOMETHING WENT WRONG DURING THE MANUFACTURING OF THE DEVICE. THE NURSE WAS NOT HARMED, AND NO PATIENT WAS INVOLVED IN THE EVENT. SEVERAL MORE PACKAGES WERE OPENED FROM THE SAME LOT; HOWEVER, STAFF COULD NOT FIND ANY OTHERS WITH THE SAME DEFECT. AFTER THE DEVICE WAS INSPECTED BY RISK MANAGEMENT AND PHOTOS OF THE DEVICE TAKEN, THE AUTO RETRACT BUTTON WAS ACCIDENTALLY TRIGGERED. ALL PORTIONS OF THE DEVICE ARE BEING RETURNED TO THE MANUFACTURER FOR INVESTIGATION/ANALYSIS; HOWEVER, THE NEEDLE IS NOW HOUSED IN THE SAFETY GUARD.
Becton dickinson/insyte autoguard 381444/none/none THE RN WAS ATTEMPTING TO START AN IV LINE WITH AN 18G CATHETER IN THE PATIENT'S LEFT ANTECUBITAL SPACE. THE RN SAW A BLOOD RETURN, INDICATING THAT THE IV LINE WAS "IN." HOWEVER, WHEN SHE PUSHED THE BUTTON TO RETRACT THE NEEDLE, IT WOULD NOT RETRACT. AT THIS POINT, THE PATIENT BEGAN MOVING AND WOULD NOT HOLD STILL. THE IV BECAME DISLODGED AND THE PATIENT PUSHED THE RN'S HAND THAT WAS HOLDING THE UNRETRACTED IV NEEDLE INTO THE RN'S OTHER HAND. THE RN WAS STUCK IN HER THUMB WITH A DIRTY NEEDLE AS A RESULT. IT IS UNKNOWN WHY THE NEEDLE DID NOT RETRACT. AFTER THE DEVICE WAS REMOVED, THE NEEDLE STILL WOULD NOT RETRACT. STAFF DISPOSED OF THE NEEDLE AND THE PACKAGING. THE RN HAS FOLLOWED UP WITH EMPLOYEE HEALTH. PATIENT WAS NOT HARMED. MANUFACTURER RESPONSE FOR SHIELDED IV CATHETER, INSYTE AUTOGUARD THE MANUFACTURER'S QUALITY DEPARTMENT HAS BEEN INFORMED OF THE EVENT.
Becton dickinson infusion therapy systems/bd insyte autoguard None/none/8340372 A NURSE REPORTED THAT THE NEEDLE FROM THE INSYTE AUTOGARD IV CATHETER WOULD NOT RETRACT WHEN SHE PUSHED THE RETRACT BUTTON. STAFF ON THE FLOOR REPORT THAT THEY HAVE EXPERIENCED THE SAME PROBLEM RECENTLY, ALTHOUGH THERE SEEM TO BE NO APPARENT DEFECTS AND NO COMMONALITIES BETWEEN THE EVENTS. IN THIS PARTICULAR EVENT, THE NURSE WAS UNABLE TO GET THE NEEDLE TO RETRACT INTO THE SAFETY COVER. THE IV WAS REMOVED AND ANOTHER WAS USED TO START THE LINE. OTHER STAFF IN THE UNIT REPORT THAT THEY HAVE NEEDED TO PUSH THE BUTTON SEVERAL TIMES IN ORDER TO GET THE NEEDLE TO RETRACT. NO STAFF MEMBER WAS INJURED IN THIS EVENT. THE PATIENT HAD TO BE STUCK TWICE IN ORDER TO ESTABLISH AN INTRAVENOUS LINE. STAFF DID NOT SAVE THE DEVICE FROM THIS EVENT. MANUFACTURER RESPONSE (AS PER REPORTER) FOR 22GA 1.00INCH 0.9X25MM IV CATHETER, BD INSYTE AUTOGUARD A COPY OF THIS REPORT HAS BEEN FAXED TO THE MANUFACTURER.
B. Braun medical/introcan safety None/425 4512/4b 13258w12 AN INFANT WAS ADMITTED WITH A FEVER AND A URINARY TRACT INFECTION (UTI). THE NURSING STAFF WAS ATTEMPTING TO START AN IV WITH THE INTROCAN SAFETY CATHETER. THE IV CATHETER STARTED LEAKING AFTER BEING INSERTED. THE PATIENT HAD TO BE RE-STUCK WITH A NEW CATHETER.
Becton dickinson infusion therapy systems/insyte autoguard intravenous catheter (18 guage 1 1/4) None/381444/8066658 THE PATIENT HAD AN INTRAVENOUS CATHETER PLACED IN PREPARTION FOR SURGERY. THE NURSE NOTICED THAT BLOOD WAS LEAKING FROM THE INTRAVENOUS CATHETER. UPON FURTHER INVESTIGATION, THE BLOOD WAS SQUIRTING OUT FROM A PIN HOLE BETWEEN THE INTRAVENOUS CATHETER AND HUB OF THE INTRAVENOUS CATHETER. THE INTRAVENOUS CATHETER WAS REMOVED AND ANOTHER INTRAVENOUS ACCESS WAS ESTABLISHED. ALL OF THE INTRAVENOUS CATHETERS FROM THAT LOT WERE REMOVED FROM ALL PATIENT CARE AREAS. THE MANUFACTURER WAS NOTIFIED AND WE ARE WAITNG TO HEAR FROM THEM.
Becton dickinson/bd insyte autoguard None/none/7124877 NEWLY OPENED ANGIOCATH WAS NOTICED TO HAVE A BENT TIP.
Becton dickinson/shielded insyte autoguard None/none/7305560 WHILE ATTEMPTING AN IV INSERTION, IT WAS NOTED THAT THE END OF THE PLASTIC CANNULA WAS CRACKED. THE TIP WAS IN ONE PIECE, BUT DID NOT ALLOW FOR SUCCESSFUL THREADING OF THE CANNULA.
Becton dickinson infusion therapy systems/bd insyte autoguard winged angiocath 8228654/381523 (22 gauge)/ 8254631, 8217913, 8191986 RETRACTABLE "SAFETY" BD INSYTE AUTOGUARD WINGED ANGIOCATHS ARE NOT RETRACTING. THE NURSE GOT NEEDLE STICK AS A RESULT OF THIS EVENT. MANUFACTURER RESPONSE FOR SAFETY ANGIOCATH, BD INSYTE AUTOGUARD WINGED ANGIOCATH BD LETTER DATED 3/17/09 RE SAMPLE - LOT 8217913, CAT # 381523 EXCESSIVE AMOUNTS OF GEL WERE PLACED IN THE GRIP ASSEMBLIES DURING MANUFACTURING.
Becton dickinson/saf-t-intima None/none/7150663 THE NURSE HAD SUCCESSFULLY INSERTED A PERIPHERAL IV. WHEN WITHDRAWING THE STYLET TO LEAVE THE PLASTIC ANGIO CATHETER IN PLACE, THE WIRE PART OF THE STYLET BROKE LEAVING THE NEEDLE AND PART OF THE WIRE WITHIN THE PLASTIC TUBING. WE HAVE NEVER SEEN THIS MALFUNCTION BEFORE. IV WAS REMOVED AND A NEW ONE WAS INSERTED. ORIGINAL PACKAGING WAS NOT SAVED BUT DEVICE WAS FROM ONE OF TWO LOT NUMBERS. THE DEVICE IS AVAILABLE TO BE PICKED UP BY A REPRESENTATIVE.
Becton dickinson infusion therapy systems/saf-t-intima 383323/none/7180035 NURSE INSERTED 22G SAF-T-INTIMA IV CATHETER AND WITHDREW THE STYLET. WHEN DEVICE WAS FLUSHED, IT LEAKED AT THE POINT WHERE THE CATHETER CONNECTS TO THE BUTTERFLY PORTION. DEVICE WAS REMOVED AND ANOTHER WAS SUCCESSFULLY INSERTED IN A NEW IV SITE. THIS IS THE SECOND OCCURRENCE OF THIS TYPE IN THE SAME DAY. BOTH DEVICES WERE FROM THE SAME LOT NUMBER BUT ONLY ONE DEVICE WAS SAVED. THE BD REP WILL BE NOTIFIED THAT THEY CAN PICK UP THE DEVICE FOR EXAMINATION.
Becton dickinson infusion therapy systems/insyte autoguard winged 381523/none/6200114 TECHNICIAN HAD INSERTED IV IN PREPARATION FOR A NUCLEAR MEDICINE SCAN. WHEN FLUSHING WITH NORMAL SALINE AFTER INSERTION, NOTED BLOODY FLUID LEAKING OUT OF IV DEVICE WHERE CATHETER ATTACHES TO HUB. IV REMOVED AND REPLACED WITH A NEW DEVICE.
Becton dickinson/bd nexiva closed iv catheter system 383505/none/7330139 NURSE SUCCESSFULLY INSERTED IV CATHETER, BUT WAS UNABLE TO REMOVE THE STYLET. REMOVED ENTIRE DEVICE AND HAD TO RESTICK THE PATIENT WITH A NEW IV CATHETER.
Becton dickinson infusion therapy systems/nexiva None/none/none IV CATHETER PLACED IN PATIENT'S BLOOD VESSEL; CATHETER WITH HOLE CAUSED BLEED. DEVICE REMOVED WITHOUT FURTHER INCIDENCE. NO PATIENT HARM.
Becton dickinson/insyte-n autoguard 24g 0.56 in; 0.7 x 14 mm/381411/none IV ACCESS WAS ATTEMPTED WITH A BD INSYTE-N AUTOGUARD. THE NEEDLE WOULD NOT RETRACT FROM THE CATHETER WHEN THE BUTTON WAS PUSHED, DESPITE THE PHYSICIAN'S AND TWO NURSES ATTEMPTS. A SECOND SITE, USING A DIFFERENT TYPE NEEDLE WAS NECESSARY IN THIS INSTANCE.
Becton dickinson infusion therapy systems/bd nexiva None/383531/6164579 A 24 GAUGE NEXIVA CATHETER FRACTURED AT THE HUB, LEAKING RESULTED. THE IV WAS REMOVED WITHOUT INCIDENT. SLIGHT RAISED DISCOLORED AREA AT SITE.
Becton dickinson infusion therapy systems/insyte autoguard None/38144/8066658 MULTIPLE REPORTS FROM MATERNITY NURSING UNIT AND ANESTHESIA STAFF OF IV FLUID LEAKING FROM THE SAME SPOT, WHERE THE CATH TUBING MEETS THE GREEN HUB. ALL IDENTIFIED AS HAVING SAME LOT NUMBER. NO PATIENT INFORMATION PROVIDED. LOT PULLED IN ALL AREAS.
Becton dickinson infusion therapy systems/bd nexiva hf 20g 1.00 in 1.1x25mm/none/9043270 AFTER SUCCESSFUL VEIN CANNULATION, WHEN THE INSERTER ATTEMPTED TO REMOVE THE STYLET, THE INNER PEICE OF THE GREY CLIP THAT HOLDS THE NEEDLE COVER IN PLACE POPPED OFF. MANUFACTURER RESPONSE FOR CLOSED IV CATHETER SYSTEM, BD NEXIVA HF REQUESTED THAT THE DEVICES BE RETURNED FOR EVALUATION.
Becton dickinson infusion therapy systems/bd nexiva 18g 1.25 inches 1.3x32mm/none/8340308 FOLLOWING SUCCESSFUL CANNULATION OF THE VEIN, THE STYLET WAS REMOVED WITHOUT RESISTANCE. IMMEDIATELY BLOOD APPEARED IN THE WHITE SEPTUM WHERE THE NEEDLE IS REMOVED FROM THE CATHETER. THE IV HAD TO BE REMOVED AND A NEW ONE INSERTED. MANUFACTURER RESPONSE FOR CLOSED IV CATHETER SYSTEM, BD NEXIVA REQUESTED RETURN OF PRODUCT FOR EVALUATION. RETURNED ON DATE OF EVENT.
Becton dickinson infusion therapy systems/nexiva hf None/383536/none THE NURSE WAS UNABLE TO REMOVE THE STYLET FROM THE BD NEXIVA CLOSED IV CATHETER AFTER SUCCESSFUL INSERTION. THE CATHETER NEEDED TO BE REMOVED AND A NEW ONE WAS INSERTED.
Unomedical/insulfon catheter None/none/none PATIENT WITH SEVERE PROTEIN C DEFICIENCY, STATUS POST (S/P) PERINATAL STROKE, WHO HAS RESIDUAL DISABILITIES FROM THE STROKE AND REQUIRES LIFELONG ANTICOAGULATION TO PREVENT RECURRENCE. HER HOME ANTICOAGULATION IS SUPERVISED BY NURSE PRACTITIONER (NP) FOR THE ANTICOAGULATION SERVICE. THE DRUG IN USE FOR PROPHYLAXIS IS ENOXAPARIN ADMINISTERED SUBCUTANEOUSLY VIA INSUFLON CATHETER. NEW CATHETER WAS PLACED LAST WEEK BY MOTHER, WHO IS EXCEPTIONALLY COMPLIANT AND CAREFUL. LAST CATHETER PLACEMENT IN THE LEFT LOWER ABDOMEN RESULTED IN AN ABDOMINAL WALL HEMATOMA, FOR WHICH SHE WAS SEEN IN THE ED. ELECTED TO CONTINUE NECESSARY ANTICOAGULATION VIA OTHER SITES; THE BLEEDING WORSENED SUBSTANTIALLY REQUIRING ADMISSION TO THE ICP, AND RED CELL TRANSFUSION. THE DIAGNOSIS IS ABDOMINAL WALL (PROBABLY RECTUS SHEATH) BLEED, NO DOUBT RELATED IN PART TO THE INSUFLON PLACEMENT, AND IN PART TO THE REQUIREMENT FOR ANTICOAGULATION.
Becton dickinson infusion therapy systems/insyte autogaurd iv catheter (blue 22ga x 1.00in safety) None/381423/8121957 WHILE STARTING A PERIPHERAL IV, THE NURSE NOTICED THAT THE FLUID WAS LEAKING FROM AROUND THE CONNECTION TO THE INSYTE HUB. THIS HAS HAPPENED AT LEAST ONE OTHER TIME RECENTLY TO ANOTHER NURSE. UPON INSPECTION OF THE RIM OF THE INSYTE, IT LOOKS AS IF THE LIP IS SLIGHTLY MELTED, NOT ALLOWING A TIGHT SEAL.
Becton dickinson/insyte autoguard needle None/none/none ACCESSED VEIN WITH 22GAUGE AUTOGUARD NEEDLE. AFTER WITHDRAWING NEEDLE FROM CATHETER, NEEDLE DID NOT RETRACT IMMEDIATELY WHEN THE BUTTON WAS PUSHED. NEEDLE WAS SLUGGISH TO RETRACT. I HAD TO WAIT, HOLDING THE IV ACCESS IN MY LEFT HAND FOR NEEDLE TO RETRACT WHILE HOLDING THE NEEDLE IN THE RIGHT HAND.
Becton dickinson/insyte autoguard None/381423/8297571 INSYTE AUTO GUARD NEEDLE IS NOT RETRACTING DURING PERIPHERAL IV INSERTION.
Becton dickinson/insyte autoguard None/381423/8297571 BD INSYTE AUTOGUARD 22G NEEDLE IS NOT RETRACTING DURING PERIPHERAL IV INSERTION.
Becton dickinson/insyte autoguard None/381434/8274614 SAFETY DEVICE ON INSYTE DID NOT WORK-NEEDLE DID NOT RETRACT WHEN BUTTON WAS PUSHED.
Becton dickinson/insyte- autoguard- shielded iv catheter None/381423/8297571 NURSE PUSHED THE RETRACTION BUTTON AND IT STUCK DOWN WITHOUT RETRACTING THE NEEDLE. NURSE PUSHED THE NEEDLE AGAINST A HARD SURFACE AND THEN IT RETRACTED.
Becton dickinson/insyte autoguard None/none/none IV ACCESSED BY 18 GAUGE NEEDLE. UPON REMOVAL OF NEEDLE BY ACTIVATING SAFETY DEVICE, THE CATHETER BECAME DISLODGED FROM THE HUB AND NEEDED TO BE RETRIEVED FROM PATIENT'S VEIN. THE CASE WAS REVIEWED LOOKING FOR TECHNIQUE. NURSE USED THE CORRECT TECHNIQUE. THEREFORE THE CAUSE WAS THOUGHT TO BE RELATED TO FAULTY CATHETER AT HUB.
Becton dickinson infusion therapy systems/bd insyte autoguard Ref 381434/8009353, h33118-3 a(8-06)/ 7116673 RN WAS STARTING IV FOR PATIENT GOING TO SURGERY. CANNULA BROKE OFF BETWEEN PLASTIC CANNULA AND HUB.
Becton dickinson/bd insyte autoguard H3116-3/ref 381423/7122242 WHEN TRYING TO RESTART AN IV ON A PATIENT THE NURSE PUSHED THE WHITE BUTTON TO RETRACT THE NEEDLE AND NOTICED THAT THE NEEDLE WAS STILL ABOVE THE SHIELD (ALMOST 1 INCH).
B. Braun medical/introcan safety None/none/none PATIENT WAS ADMITTED TO THE HOSPITAL TO RULE OUT SEPSIS. HIS HOSPITAL COURSE WAS UNCOMPLICATED. HIS BLOOD CULTURES, CEREBROSPINAL FLUID CULTURE, AND URINE CULTURE WERE ALL NEGATIVE. WHILE PREPARING PATIENT FOR DISCHARGE TO HOME, THE INTRAVENOUS (IV) ACCESS WAS DISCONTINUED, HOWEVER WHEN IT WAS DISCONTINUED A PIECE OF THE IV CATHETER BROKE OFF AND STAYED WITHIN THE VEIN OF THE SCALP. SURGERY WAS ALERTED AND EVALUATED THE PATIENT. IT WAS DETERMINED THAT THE CATHETER COULD NOT BE REMOVED AND THE PATIENT WAS SCHEDULED FOR SURGERY. A CT SCAN LOCALIZATION IDENTIFIED THE CATHETER AND THE SURGEON WAS ABLE TO REMOVE THE TIP OF THE CATHETER UNDER GENERAL ANESTHESIA. BECAUSE THE PATIENT WAS PLACED UNDER GENERAL ANESTHESIA, HE WAS KEPT OVERNIGHT FOR OBSERVATION. THE PATIENT WAS DISCHARGED HOME IN A STABLE CONDITION. THE PRODUCT WAS RETAINED BY RISK MANAGEMENT; HOWEVER NO PRODUCT INFORMATION WAS AVAILABLE.
Smiths medical asd/acuvance safety i.v. catheters 24g safety catheter/335304/none PATIENT HAD 24G ACUVANCE IV INSERTED DURING THE MORNING HOURS. DURING THE EVENING HOURS, WHILE THE PATIENT WAS BEING HELD BY HIS PARENT, IT WAS NOTED THAT IV TUBING CAME APART AT THE HUB AND BLOOD WAS LEAKING OUT. IV DID NOT HAVE TO BE REPLACED AND NO PATIENT HARM WAS NOTED.
Becton dickinson infusion therapy systems/bd insyte autoguard venous catheter - 18 ga 1.16in None/none/8284277 LABORING PT - STARTING IV AND CATHETER BROKE OFF AT THE HUB AND WAS RETAINED IN PATIENT'S ARM. PT WAS BEING INDUCED SO WAS BEING ALLOWED TO LABOR AND DELIVER AND THEN CATHETER WOULD BE REMOVED BY STAFF VASCULAR SURGEON.
Becton dickinson infusion therapy systems/insyte autoguard None/8134797/none NEEDLE RETRACTED AND COULD NOT THREAD CATHETER, PATIENT REQUIRED RESTICK.
Smiths medical md/jelco protectiv plus safety None/3060/38b27sc05 A 22G ANGIOCATH WAS EASILY INSERTED INTO THE PATIENT'S RIGHT FOREARM; HOWEVER, THE ANGIOCATH WOULD NOT FLUSH. WHEN AN ATTEMPT WAS MADE TO REMOVE THE ANGIOCATH, THERE WAS SOME RESISTANCE. WHEN THE CATHETER WAS REMOVED IT WAS NOT INTACT. THE MD WAS NOTIFIED AND AN X-RAY WAS ORDERED. THE SHEARED PORTION OF THE CATHETER WAS FOUND TO BE SUBCUTANEOUS AND WAS NOT REMOVED. THE REMAINDER OF THE CATHETER WAS SAVED AND WILL BE RETURNED TO THE MANUFACTURER UPON REQUEST.
Becton dickinson/bd insyte autoguard None/none/7348099 AN 18 GAUGE INSYTE AUTOGUARD WAS BEING INSERTED INTO THE PATIENT'S ARM. WHEN THEN THE RETRACTION WAS DEPLOYED USING THE PUSH BUTTON, THE GREEN HUB OF THE IV WAS SEEN DANGLING FROM THE PATIENT'S ARM/INSERTION SITE. THE CATHETER WAS "MISSING." THE CATHETER COULD NOT BE LOCATED AT FIRST. THE PATIENT WAS X-RAYED AND THE CATHETER WAS NOT LOCATED. THE BD REPRESENTATIVE CAME OUT AND WAS ABLE TO SEE WITH MICROSCOPIC LENSES THAT THE CATHETER HAD ACTUALLY RETRACTED BACK INTO THE RETRACTION DEVICE OF THE IV.
Becton dickinson infusion therapy systems/bd insyte autoguard None/none/7340858 AN 18 GAUGE 1.16 INCH IV CATHETER BEING INSERTED TO LEFT WRIST, NURSE WENT TO ADVANCE CATHETER AND NOTED CATHETER NO LONGER ATTACHED TO HUB. CATHETER APPEARS TO BE IN RETRACTION CHAMBER. MANUFACTURER RESPONSE FOR 18 GAUGE SHIELDED IV CATHETER, BD INSYTE AUTOGUARD LOCAL REPRESENTATIVE AVAILABLE ON SITE TO EXAMINE CATHETER.
Becton dickinson/bd instye autoguard None/none/7352356 STAFF MEMBER ATTEMPTED TO INSERT AN 18 GAUGE IV CATHETER INTO LEFT FOREARM. THE CATHETER PUNCTURED THE SKIN, BUT THEY WERE UNABLE TO ADVANCE THE CATHETER. AFTER THE CATHETER WAS REMOVED, IT WAS NOTED THAT THE TIP OF THE CATHETER WAS MISSHAPED, AND APPEARED TO BE DEFECTIVE.
Becton dickinson/intima None/none/7215265 AFTER CANNULATING THE VEIN AND THE NEEDLE WAS REMOVED, WHILE FLUSHING THE CATHETER, I NOTICED THAT THERE WAS A HOLE IN THE TUBING AT THE HUB WHERE THE HUB AND THE TUBING MEET.
Becton dickinson infusion therapy systems/bd insyte autoguard shielded iv catheter None/381544/8011121 FLASH OF BLOOD OBSERVED IN HUB UPON INSERTION. ENTIRE NEEDLE ADVANCED. AT THAT TIME IT WAS NOTED THAT NO PLASTIC CATHETER WAS ATTACHED TO THE GREEN HUB. CATHETER WAS NOT IN THE PACKAGE AND WAS MISSING ENTIRELY.
B. Braun medical/introcan safety None/4252560-02/7l22258248, 7k02258n27 THE IV WAS STARTED WITH AN 18 G CATHETER. THE NURSE VERBALIZED THAT THE IV CATHETER WAS INSERTED WITHOUT DIFFICULTY AFTER APPROPRIATE SKIN PREP. SHE NOTED THAT THE PATIENT HAD "GOOD" VEINS AND THAT THEY WERE LARGE AND THAT SHE HAD NO PROBLEMS AT ALL. THE PATIENT RECEIVED 4MG MORPHINE THROUGH THE IV 20 MINUTES LATER. THE PATIENT ALSO HAD A CT DONE 40 MINUTES AFTER THE IV WAS STARTED. THE NURSE DID NOT NOTICE ANY REDNESS OR SWELLING OR ANY SIGNS OF INFILTRATION AND ADMINISTERED THE MORPHINE WITHOUT DIFFICULTY. PATIENT DID NOT HAVE ANY COMPLAINTS OF PAIN IN THE RIGHT ARM OR AT THE INSERTION SITE. THE IV WAS REMOVED BY ANOTHER NURSE 2 HOURS AFTER PLACEMENT. IT WAS NOTED TO BE "BROKEN OFF" AT THAT TIME AND DOCUMENTED. TWO PHYSICIANS WERE THEN NOTIFIED FOR FURTHER EVALUATION. THE NURSE WHO STARTED THE IV WAS SPECIFICALLY ASKED IF SHE HAD SLID THE NEEDLE PORTION IN AND OUT OF THE CATHETER PORTION AT ALL. SHE SAID THAT SHE DID NOT, AND STATED THAT SHE KNEW THIS WAS SOMETHING THAT SHOULD NOT BE DONE. AFTER THE FRACTURED CATHETER WAS DISCOVERED AN X-RAY WAS DONE THAT CONFIRMED A RETAINED PORTION OF CATHETER. A PARTIAL CUT DOWN WAS PERFORMED IN THE OR UNDER LOCAL ANESTHESIA AND NO FOREIGN BODIES WERE FOUND. FOLLOWING THE OR, A CHEST X-RAY AND CHEST CT SCAN WERE DONE AND THE CATHETER WAS NOT FOUND IN THE LUNGS OR CHEST. CONSULTS WITH RADIOLOGY, VASCULAR SURGERY, CHEST SURGERY, PEDIATRICS, AND ANESTHESIA FOLLOWED.
Becton dickinson infusion therapy systems/insyte autoguard B-d 18 guage insyte autoguard/none/none NURSE WAS DISCONTINUING THE CATHETER FOLLOWING AN INTERMITTENT INFUSION. SHE REMOVED THE TAPE AND STATLOCK. WHEN PULLING ON THE ULTRASITE ADAPTER AND THE HUB, IT SEPARATED FROM THE ACTUAL CATHETER. NURSE WAS ABLE TO REMOVE THE CATHETER IN ITS ENTIRETY WITH HER FINGERS.
Becton dickinson/insyte autoguard Ref381444/none/7352356 RN WAS INSERTING #18 ANGIOCATH. WHEN THE WHITE BUTTON WAS RELEASED FOR RETRACTION OF THE NEEDLE, BLOOD FLEW INTO THE BOTTOM OF THE PLASTIC CONTAINER AND SQUIRTED OUT OF THE HOLE IN THE BOTTOM OF THE PLASTIC CONTAINER.
Becton dickinson infusion therapy systems/bd insyte autoguard winged 24ga 0.75 in None/ref 381512/none NURSE PREPARING TO PLACE AN INTRAVENOUS CATHETER IN THE PATIENT AND WHEN THE NURSE OPENED THE BD 0.75 INCH IV NEEDLE, THE PLASTIC CATHETER FELL OFF THE NEEDLE HUB. THE NEEDLE ITSELF HAD ALREADY BEEN RETRACTED INTO THE HUB AND WAS BENT BEFORE THE STERILE PACKAGE WAS OPENED. ANOTHER INTRAVENOUS CATHETER WAS USED TO PLACE THE IV IN THE PT.
Smiths medical md/protectiv 3050/none/none WHILE INSERTING A PIV 22 GAUGE CATHETER, RN WAS UNABLE TO RETRACT THE NEEDLE AFTER RECEIVING A BLOOD RETURN.
Smiths medical md/protect iv safety iv catheter None/none/37k30sc06 IV CATHETER WAS BEING INSERTED AND IT HIT A VALVE. NURSE WITHDREW CATHETER AND NOTICED IT TO BE SHORTER THAN NORMAL. THE END OF (20 GAUGE) CATHETER WAS MISSING WITH ROUGH EDGE.
Smiths medical md/20gx1" protectiv plus safety i.v. catheter radiopaque 3067/none/none THE NURSE HAD INSERTED A NUMBER 20 GAUGE CATHETER INTO THE PATIENT'S ARM. THE NEEDLE WAS RETRACTED AND THE CATHETER WAS FOUND LEAKING AROUND THE HUB. WHILE FLUSHING TO CHECK FOR PATENCY, IT WAS NOTED THAT SALINE WAS COMING OUT FROM AROUND THE HUB OF THE CATHETER. UPON INSPECTION OF THE HUB, IT WAS FOUND TO BE BROKEN. NO INJURY TO THE PATIENT.
Becton dickinson infusion therapy systems/intravenous catheter 18 gauge 381444/8009355 h3120-3 a(8-06)/ 7291865, 72412787, or 7144153 WHILE PREPARING THE PATIENT FOR DISCHARGE FROM OUTPATIENT SURGERY, THE NURSE REMOVED THE IV SITE DRESSING THAT SECURED AN 18 GAUGE ANGIO CATHETER. AS SHE REMOVED DRESSING, THE HUB OF THE CATHETER FELL TO THE FLOOR WHILE APPROXIMATELY 1 INCH OF THE CATHETER REMAINED IN THE PATIENT'S LEFT ARM. THE RETAINED CATHETER WAS REMOVED UNDER FLUOROSCOPY. UPON INSPECTION OF THE BROKEN CATHETER IT APPEARED TO BE A COMPLETE, CLEAN BREAK WITH NO JAGGED EDGES, BENDS OR SHEARING.
Becton dickinson/bd insyte autoguard 381434/381434/7200338 RN STARTED AN IV ON THE PATIENT. THE IV WENT IN EASILY UNTIL THE RN TRIED TO THREAD THE LAST 1/4 INCH OF THE CATHETER. THE RN THEN NOTICED THAT BLOOD WAS LEAKING OUT OF THE END OF THE CATHETER CLOSEST TO THE PINK HUB. RN REALIZED THE CATHETER WAS DEFECTIVE AND TRIED TO RETRACT THE NEEDLE. THE NEEDLE WOULD NOT RETRACT. RN GRABBED THE END OF THE PINK HUB AND IT PULLED AWAY FROM THE PATIENT WITHOUT THE CATHETER. RN WAS ABLE TO GRAB THE END OF THE CATHETER AND PULL IT OUT BEFORE IT MIGRATED INTO THE VEIN. RN NOTICED THAT THE CATHETER NEAREST THE PINK HUB HAD A LARGE HOLE IN IT.
C.r. bard inc., bard electrophysiology division/ssv None/808700/s25589 THERE WERE TWO EVENTS REPORTED WITH THE SAME ISSUE. THE NEEDLE WHICH CAME WITH THE SSV KIT WOULD NOT ACCEPT ANY WIRE (2 WIRES ATTEMPTED). THE NURSE HAD TO RESTICK THE PATIENT WITH ANOTHER NEEDLE. THREE DAYS LATER, THE GUIDEWIRE THAT CAME WITH THE SHEATH WOULD NOT PASS THROUGH THE ACCESS NEEDLE THAT CAME WITH THE SHEATH. AGAIN, THE PATIENT REQUIRED A SECOND ACCESS STICK WITH A NEW NEEDLE. NEITHER PATIENT WAS HARMED, BUT THE ENTIRE LOT WAS PULLED FROM THE SHELF AND RETURNED TO THE MANUFACTURER.
Becton dickinson/insyte, autoguard None/none/7345737 THE CATHETER WAS BEING INSERTED INTO A PATIENT FOR RADIOLOGY TESTS; THE CATHETER IS INTRODUCED WITH THE NEEDLE, WHICH IS THEN WITHDRAWN (BY A SPRING MECHANISM IN THE SYRINGE) WHILE THE CATHETER STAYS IN PLACE. WHEN THE SYRINGE WAS WITHDRAWN, THE HUB WAS DETACHED FROM THE CATHETER. THE CATHETER WAS FOUND TO HAVE NOT DETACHED FROM THE NEEDLE, AS IT WAS SUPPOSED TO; AND IT WAS FOUND IN THE SYRINGE. SINCE IT DETACHED FROM THE HUB, THE CATHETER COULD HAVE EMBOLIZED IN THE PATIENT HAD IT NOT BEEN WITHDRAWN BACK INTO THE SYRINGE. IN THIS EVENT THE PATIENT WAS NOT INJURED, BUT REQUIRED AN ADDITIONAL NEEDLE STICK.
Becton dickinson infusion therapy systems/insyte autoguard 20 gauge/none/8039726 THE PATIENT WAS IN THE POST-ANESTHESIA RECOVERY UNIT, WHEN THEY LIFTED THEIR HAND AND A SNAP WAS HEARD. THE IV WAS NOTED TO BE LEAKING AND WAS CRACKED AT THE HUB. IV ADMINISTRATION WAS DISCONTINUED, AND THE PATIENT WAS NOT HARMED AS A RESULT OF THIS INCIDENT.
Becton dickinson/bd insyte autoguard 20 ga 1.00in/ref 381433/8116575 WHEN INSERTED INTO THE PATIENT'S VEIN, THE CATHETER DID NOT SLIDE OFF THE NEEDLE AS EXPECTED, SO IT DID NOT SEAT PROPERLY IN THE VEIN. THE NEEDLE RETRACTED AS EXPECTED, BUT THE CATHETER DID NOT ADVANCE, AND HAD TO BE REPLACED. PATIENT WAS NOT HARMED, BUT HAD AN ADDITIONAL VENIPUNCTURE AS A RESULT. WE HAVE HAD 3 PRIOR INSTANCES OF CATHETERS NOT WORKING PROPERLY, AND HAVE PULLED ALL DEVICES OF THIS LOT # AND ARE REQUESTING REPLACEMENT PRODUCT.
Becton dickinson infusion therapy systems/bd insyte autoguard winged None/none/none AN #18 INSYTE CATHETER WAS BEING INSERTED IN THE RIGHT FOREARM OF A PT. WHILE A STRIP OF TAPE WAS BEING PLACED UNDER THE CATHETER HUB TO STABILIZE THE SITE, THE TAPE STUCK TO THE RN'S GLOVE AND IV CATHETER AND HUB TURNED TO THE LEFT 90 DEGREES. RN STRAIGHTENED THE HUB AND CATHETER NOTICING AT THE SAME TIME THAT A SMALL HEMATOMA STARTED TO DEVELOP. TAPE WAS APPLIED OVER THE HEMATOMA AND THE WINGS OF THE HUB WERE TAPED DOWN. THE METAL NEEDLE WAS RETRACTED WITH NO BLOOD RETURN. A SALINE SYRINGE WAS ATTACHED TO THE HUB TO FLUSH THE CATHETER. AT THAT TIME, SALINE SQUIRTED AROUND THE HUB. THE SYRINGE WAS TIGHTENED AND SALINE WAS FLUSHED A SECOND TIME. SALINE AGAIN SQUIRTED AROUND THE HUB. THE TAPE WAS REMOVED FROM THE IV SITE OVER THE WINGS OF THE CATHETER AND OVER THE SITE OF THE HEMATOMA. ON REMOVING THE CATHETER WITH THE SALINE SYRINGE ATTACHED, THE HUB ONLY WAS WITHDRAWN. IMMEDIATE PRESSURE WAS APPLIED TO THE VEIN AND THE ER MD WAS CALLED TO THE BEDSIDE. MD PALPATED THE VEIN WITH NO CATHETER FELT. X-RAYS DONE ON THE FOREARM, HUMERUS, AND CHEST AS WELL AS A CT SCAN W/O CONTRAST. RESULTS WERE INCONCLUSIVE. EVENT DISCLOSED TO PATIENT AND FAMILY. HEALTHCARE PROFESSIONAL IMPRESSION: IT APPEARS THAT THERE MIGHT HAVE BEEN A FLAW IN THE CATHETER IN THAT THE METAL PIECE IN THE HUB WAS MISSING. THIS COULD HAVE ALLOWED FOR CATHETER DISPLACEMENT.


Additional Information:

[1] University of Cincinnati, The Ohio State University, and Case Western Reserve University. Anesthesia: Intravenous Catheter Complications. NetWellness Consumer Health Information. Last reviewed June 18, 2007, by Gareth S. Kantor, M.D.
http://www.netwellness.org/healthtopics/anesthesiology/ivcomplications.cfm


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