The charge nurse found the patient bleeding from iv access due to failed connection.The one-link needle free iv connector came unscrewed from the non-dehp standard bore catheter extension.The patient lost approx.20-30 cc of blood.The needle free connector did not come loose from the iv line tubing and pump, allowing continued flow of infusion (heparin).The nurse changed the one-link needle free connector to resolve the problem.The nurse believes that the plastic wings on the catheter extension set are situated in such a way that it allows for an incident loosening of the luer lock connection, which is what was believed to have occurred.
|