We tried to place a bravo/esophageal ph monitor, it suctions to the esophageal wall, the device was setup and ready to go.The gi doctor performing the procedure placed the monitor with the delivery device, turned the suction on for 30 seconds as directed and deployed it.On recheck with the endoscope the bravo monitor had not attached properly to the esophageal wall, it was near the vocal cords.The device was setup correctly and seemed to be no user/operational errors to my knowledge, the monitor/delivery device could possibly defective or the suction equipment was not in proper working condition.The delivery device could've not been close enough to the esophagus wall or moved away from it somehow before suction was turned on.It resulted in the patient having an emergent bronchoscopy done to remove the ph monitor from one of her lungs which was done successfully.Suction was checked prior to use.This is the 3rd case i am told where this has occurred.We have another one scheduled monday and will see if the rep can come check the machine.Device/delivery system and packaging not saved.
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