The event involved an 8" (20 cm) ext set w/microclave® clear, chemolock¿ port, y-connector, rotating luer where an epirubicin leaked from device after administration, exposing both patient and staff to unnecessary cytotoxic agent that remained inside the device.The patient was exposed to the drug on her bare skin and likely inhaled some chemo particles.The healthcare providers were wearing procedural masks upon discovering the hazardous spill, so may have inhaled some chemo particles.The leak occurred distal to the pump, blue clave cap region, and there was no filter indicated for this protocol.The set up was: regular non-deph iv tubing set, then cl3950, then a y-set extension directly to patient¿s iv cathlon.There was no hole, cut, tears or any defect noted.There was patient involvement but no patient harm.This is the first of three reports.
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