Received notice on voluntary event report (mw5056356) regarding an incident.Event description is as follows: this event involved (b)(6) y/o male who was at (b)(6) on (b)(6) 2015 for an interventional radiologic procedure in operating room 5.This pt has a lot standing history of diabetes, peripheral vascular disease, cigarette smoking, coronary artery disease and atrial fibrillation.Pt was taken to the cath lab for an angiogram.This angiogram showed an occluded superficial femoral artery.The interventional radiologist was able to perform an angioplasty and stents were open, but on final angiographic films, a large thrombus was noted in the common femoral artery extending into the deep and superficial femoral arteries.Ultimately, a vascular surgeon was contacted as this appeared to be a surgical lesion.As this surgical procedure began, coagulation parameters were sent as well as an act.The act was actually repeated twice, and the results kept coming back in the 400-500 sec range.The pt had received 12,000 units of heparin in the cath lab, and also received tpa.Due to the multiple episodes of unexplained clotting, difficulty to anticoagulated and keep stents open, the vascular surgeon elected to perform a femoral to above the knee popliteal bypass.Based on further inquiry, it turns out that the initial acts were sent in the wrong syringe which were inappropriately heparinized, giving a falsely elevated reading.The vascular surgeon then asked that the pt receive 5000 units of heparin.Mr.(b)(6) received heparin a number of add'l times throughout the case at appropriate intervals, and acts were checked at appropriate intervals throughout the rest of the case.Diagnosis or reason for sure: syringe used to obtain blood sample for act study.
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