MAUDE Adverse Event Report: HEPARIN LOCK FLUSH 1ML SYRINGE; SALINE, VASCULAR ACCESS FLUSH

Patient Problem Insufficient Information (4580)

Event Type  Other  

Event Description

Pharmacy received an email from our nursing manager that the wrong heparin flushes were stocked in our automated dispensing cabinet.Normally, the unit keeps heparin flush 10 units/ml 5 ml syringes (50 units/5ml) stocked.The unit ran out and asked the pharmacy to stock more during the day.The technician accidentally stocked heparin flush 10 units/ml 1 ml syringes.The products look nearly identical so it's easy to see how they were mixed up.Unsure how the barcode was bypassed when stocking the adc.Ref report: mw5150459.(b)(4).

• Brand Name: HEPARIN LOCK FLUSH 1ML SYRINGE
• Type of Device: SALINE, VASCULAR ACCESS FLUSH
• MDR Report Key: 18534976
• MDR Text Key: 333259669
• Report Number: MW5150460
• Device Sequence Number: 1
• Product Code: NGT
• Combination Product (y/n): N
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Voluntary
• Reporter Occupation: Unknown
• Type of Report: Initial
• Report Date: 01/17/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: No
• Initial Date Manufacturer Received: Not provided
• Initial Date FDA Received: 01/17/2024
• Patient Sequence Number: 1