[16224103]
Hfov pediatric oscillator failed while in use on the pt. Stopped running. The pt's bp dropped. The pt was manually bagged, dopamine drip was increased and epi drip started. A ns bolus was given. A replacement machine was obtained and started on the pt without incident. The following info was obtained in our investigation: the mushroom caps/valves that we have currently are all from various lot numbers. I have inspected several different packages and i am unable to detect from the naked eye any differences between any of them, they all look the same to me. We did order additional supplies and they were overnighted and should be here tomorrow. The rt who spoke directly to technical support. The call went out (b)(6) about 9. They went through a series of trouble shooting checks; the last thing they tried was to apply external pressure to the mushroom cap to see if that was where the leak was possibly at. (b)(6) stated that with pressure on the cap, the pressure within the oscillator did come up. (b)(6) then replaced the caps and the oscillator; subsequently the oscillator operated normally. Technical support did indicate to her, (b)(6), that there had been some issues with the mushroom caps recently, but did not elaborate on specifics. At the time of the call, (b)(6)'s intent was to trouble shoot the machine and get the pt placed on it. She did not inquire as to specific lot numbers of the caps; however, did inquire about recall issues when she was told that the issues didn't meet fda requirements for recall.
Patient Sequence No: 1, Text Type: D, B5