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Model Number SET |
Device Problem
Therapeutic or Diagnostic Output Failure (3023)
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Patient Problem
Insufficient Information (4580)
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Event Date 12/07/2021 |
Event Type
malfunction
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Event Description
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Reporting as 4th occurrence in the past 6 months involving the dialynate system.At approximately 0130, rn began to question the patient's ability to ultrafiltrate (uf) consistently throughout the shift with peritoneal dialysis (pd) flushes when patient wasn't undergoing any pd dwells.On average, patient had been uf'ing 5-15 ml every hour.Given previous instances of equipment malfunction with manual pd use recently, rn decided to perform a flush of dialysate from the buretrol chamber to the collection bag, bypassing the patient.Three separate flushes were trialed (50ml, 70ml, and 100ml, respectively) directly into the collection bag, and all three outputs resulted in 10 ml above the instilled amount (60ml, 80ml, and 110ml, respectively).This discrepancy was clearly indicative of an equipment issue, likely having to do with inaccurate stamping of the measurement grid on the collection bag chamber.As a result, patient's intake and output documentation was inaccurately being reflected on the chart.Clinically, this meant that the patient was more fluid-positive that what our documentation up to this point had showed.This is a significant patient safety issue, particularly with a 7-kilo dialysis patient whose daily intake and output continuously dictates daily therapies and clinical interventions.
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Event Description
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Reporting as 4th occurrence in the past 6 months involving the dialynate system.At approximately 0130, rn began to question the patient's ability to ultrafiltrate (uf) consistently throughout the shift with peritoneal dialysis (pd) flushes when patient wasn't undergoing any pd dwells.On average, patient had been uf'ing 5-15 ml every hour.Given previous instances of equipment malfunction with manual pd use recently, rn decided to perform a flush of dialysate from the buretrol chamber to the collection bag, bypassing the patient.Three separate flushes were trialed (50ml, 70ml, and 100ml, respectively) directly into the collection bag, and all three outputs resulted in 10 ml above the instilled amount (60ml, 80ml, and 110ml, respectively).This discrepancy was clearly indicative of an equipment issue, likely having to do with inaccurate stamping of the measurement grid on the collection bag chamber.As a result, patient's intake and output documentation was inaccurately being reflected on the chart.Clinically, this meant that the patient was more fluid-positive that what our documentation up to this point had showed.This is a significant patient safety issue, particularly with a 7-kilo dialysis patient whose daily intake and output continuously dictates daily therapies and clinical interventions.
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