A patient was admitted for labor and delivery.
The anesthesia provider tried to place an epidural catheter.
Minimal resistance was met.
After loss of resistance, the catheter failed to thread, and the needle was removed.
At that time, it was noted that the tip of the tuohy needle was bent forward, partially occluding the orifice.
It is uncertain whether the tip was bent prior to insertion or during placement.
There is concern that the tip should not bend and can create a safety issue as it can shear the catheter upon threading.
A similar event reportedly occurred with a different patient in the cardiac operating room (o.
R.
) recently.
We are unsure if there is an issue with this lot.
The patient required general anesthesia for a c-section.
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