Received from australia: extensive blood loss and loss of consciousness was reported after a venous fistula needle in the left forearm that was affixed with 3m micropore surgical tape dislodged.A code blue was called, and an emergency medical and nursing team stabilized the patient; fluid resuscitation was performed, digital pressure was applied to stop the further blood loss from the fistula and blood from the dialysis circuit was returned to the circulation.The patient was transferred to the emergency department for further treatment, which included fluid administration, monitoring and hospital admission.Status is stable with no further needle dislodgements.The device used at the time was not documented in the medical records; the facility stocked both 3m micropore surgical tapes 1533-1 (tan) and 1530-1 (white) on the unit, so either could have been used (refer to emdr 2110898-2023-00104 regarding same complaint).The hospital reported that unit changes were made in response to this incident which included staff education and new securement practices with extra pieces of tape used to secure needles to the skin, sourcing of new silicone tape that is now used to secure all av fistula needles, an audible alarm for the patient placed next to the venous needles to detect blood loss if the needle is dislodged, and patient education on keeping the arm still, not touching av fistula tapes.Monitoring the needle position, and letting staff know if the needles are moving.
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