A user facility administrator reported that a dialyzer blood leak occurred immediately after the initiation of the patient¿s hemodialysis (hd) treatment.
The blood went immediately into the venous hansen.
The blood was not returned to the patient.
Blood was visible in the hansen.
The blood leak was noted as being an internal blood leak.
The machine, a fresenius 2008k machine, alarmed appropriately with a blood leak alarm.
The test strips were not used because the blood was visually seen.
The patient¿s estimated blood loss (ebl) was approximately 200 ml.
There was no patient injury, adverse events, or medical intervention required as a result of this event.
The patient was restarted on a new machine and treatment completed successfully with new supplies.
The complaint device was reported to be available to be returned to the manufacturer for evaluation.
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