It was reported that during a procedure, it was found that the guide wire of a portex® ultraperc® single dilator technique kit with a blue line ultra® tracheostomy tube was found to be thicker than the catheter.The fault was found while trying to pass the metal guide through the catheter and the guide did not pass.The guidewire's thickness was checked at the step was repeated.During this process, the patient was punctured three times.The catheter was exchanged for a venous catheter and a guide belonging to another kit.During dilation, the patient was desaturated, and transesophageal abundant bleeding was detected by a potential thyroid puncture.It resulted in bradycardia and the use of a mechanical ventilator was necessary.No permanent injury was reported, and the outcome of the incident was reported as resolved.
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