A report was received on 23 sep 2022 from the home therapy nurse (htn) of a (b)(6) year old female with a medical history including multiple comorbidities and end stage renal disease, who stated the patient experienced an estimated blood loss of 100mls due to an unclamped heparin infusion line during a hemodialysis treatment on (b)(6) 2022.Emergency medical services were called and the patient was transported to hospital, where she was admitted on (b)(6) 2022 and discharged on (b)(6) 2022.Additional information was received on 27 sep 2022 from the htn who stated the patient experienced feeling lightheaded and short of breath.Per htn, the blood leak is due to use error and originated from the heparin line not being clamped.The patient has recovered without sequelae and has resumed therapy with the nxstage system.
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