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Catalog Number 2C8541 |
Device Problem
No Flow (2991)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 08/19/2021 |
Event Type
malfunction
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Manufacturer Narrative
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(b)(4).Should additional relevant information become available, a supplemental report will be submitted.
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Event Description
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It was reported a clearlink system continu-flo solution set with duo-vent spike would not flow.The day prior to the event occurrence, a fentanyl drip was initiated at 0300 at a rate of 2.3 ml/hour.At 0600 the rate was decreased to 1.9 ml/hour.At 0800 or 0900 the drip was stopped.The day of the event at 0200 the fentanyl was not going to be restarted so the nurse went to waste the remaining solution.That is when it was observed that all 50mls of the solution remained in the solution bottle.The patient should have received approximately 12.6mls of fentanyl.The set was used in conjunction with a baxter pump.There was no report of patient injury or medical intervention associated with this event.No additional information is available.
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Manufacturer Narrative
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H10: the device was not returned and the lot number is unknown; therefore, a device analysis could not be completed.Should additional relevant information become available, a supplemental report will be submitted.
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Search Alerts/Recalls
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