[17765945]
On monday, september 29,1997, a facility was being dialyzed. The pt began to experience symptoms of hemolysis. There are contradicting stories as to when hemolysis occurred. One nurse said the hemolysis occurred within the first hour to hour and a half, while another nurse said the hemolysis occurred after saline was infused to alleviate a hypovolemic event. Two similar events occurred previously; (one prior to may 1997 and another in may 1997). In line diagnostics corp. (idc) was not notified of any incidents until september 29,1997. All three pts involved were taken off dialysis and monitored for further complications. All pts fully recovered. In may, 1997 the facilities med director and his staff conducted a thorough investigation with no absolute conclusion as to the cause of these three events. When the third event occurred in september, the med director reported to co that he found three commonalities in each of the three cases: 1. A baxter ct190 dialyzer was used. 2. A cobe c3 machine and tube set was used. 3. A disposable blood chamber from idc was used. Add'l items noted were: a. There was a leak in the dialysis circuit (either between the dialyzer and the blood chamber or between the blood chamber and the tubing set) b. The renalin flush performed prior to the pt hook-up, was conducted a second time (or more) after failing the initial renalin test. C. In each instance, the dialyzer, tubing set, and blood chamber was discarded by facility.
Patient Sequence No: 1, Text Type: D, B5