As reported by the user facility: event 1 : five (5) patients have had iv lines ruptures.Assessment: nicu patients requiring a large volume continuous infusion (ivf, tpn etc.), a space pump burette set is used for the iv assembly.Nicu staff have observed and recognized frequent pump alarms indicating air in the tubing.Additional information one nicu patient with a space pump burette set was recently found with a positive bc - s.Aureus on (b)(6) 2022.The patient had a picc line in place from (b)(6), cst determined the case to be a secondary bsi due to pneumonia.Patient born on (b)(6) 2022 with rds, intubated (b)(6) 2022, (b)(6) 2022 imaging with bilateral consolidation, residual hazy opacities, which continued through admission.Bc collected on (b)(6) 2022 due to recurrent apneas, desats, bradys.Id consult from dr.(b)(6) on (b)(6) 2022 indicated - absence of neutrophilia and rapid resolution of symptomatologic does suggest possible contaminant.If the repeat bc obtained following only single dose of vancomycin remains without growth, this may further suggest possible contaminated specimen (repeat bc on (b)(6) 2022 negative).Low risk for cns infection suggested given clinical course and prompt institution of antibiotic tx, continue oxacillin to compete 10 day course for presumed mssa bacteremia.The patient started with space pump burette set on (b)(6) 22 with tpn administration.It is unclear how many port access were performed on the patient since the administration of tpn or if the space pump burette contributed to the positive bc.
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