[16548568]
For the last seven months, there have been 27 events involving dislodgement of picc lines with the sorbaview securement dressing. The dislodgement was often noticed prior to or during other care. Dressings in these events were in place for differing periods of time (e. G. : 1, 2, 4, 6, and 7 days). The proper dressing technique: cross the flap and keep the hub of the catheter/line under the sorbaview. A house-wide re-education effort with the manufacturer's rep was completed. Even with the correct dressing application, lines are found out while the dressing remains intact. Troubleshooting has included:1. Additional adhesive added to dressing change kits. 2. Contact with manufacturer's rep to provide additional education to nursing staff. 3. No scissors used during dressing change. Reports of this type of event include descriptions of the dressing remaining intact, but the line was falling out or completely out. Some events have noted that iv lines were attached to the iv access point. Others had no lines attached (e. G. : capped triple lumen catheter and picc line). Examples of patient activity during this event type include: 1. Lying still in bed. 2. Turning in bed. 3. Staff transferring patient from or bed to unit bed. 4. Ambulating in room. 5. Standing for xray. 6. Scratching his neck. 7. Showering. Patient outcomes have included:1. Another central line insertion. 2. Peripheral line insertion. 3. Line remained out. 4. Io (intra-osseous) line placement. Some effects on the patient include:1. Delay in receiving pain medication. 2. Fluid infiltration. 3. Bleeding from iv access point. 4. Delay in testing (procedures requiring dye injection). 5. Difficulty accessing intravascular space during code. Site locations include:1. Antecubital. 2. Forearm. 3. Internal jugular. 4. Anterior chest.
Patient Sequence No: 1, Text Type: D, B5