[1101741]
The rn was preparing to start an iv. The nurse opened the iv start kit and discovered that the chlora prep sepp applicator was empty. The iv start kit and the chlora prep packaging was intact, as was the applicator--but no liquid was inside it. The rn opened another kit and had the same findings: intact applicator but no liquid inside it. A third kit was opened, and staff found that the applicator did have fluid inside. Staff did not save the device or the packaging, although they did note the lot numbers and device information from both the kits and the applicators. Both kits that were faulty came from the same lot numbers as did both applicators. The remaining stock on the unit was checked, but no other problematic devices were found. The remaining kits on the unit are all from the same lot numbers as the ones reported here. The kits are stored in their own bin inside a temperature & humidity controlled room and are not exposed to heat or cold extremes. No condensation was seen in any of the kits affected or on the shelf in the storage room. Manufacturer response (as per reporter) for iv start skin disinfectant, chloraprep seppa copy of this report has been faxed to medline and to cardinal health.
Patient Sequence No: 1, Text Type: D, B5