[19035865]
Eval was interviewing quality mgr and dialysis nurse mgr in 2007. Dialysis nurse mgr stated pt dialyzed in chronic dialysis unit, on the 2nd shift of pts, one month earlier. The dialyzer was from baxter and equipment used was a cobe c3 delivery system with gambro blood tubing. Pt complained of chest pain 2-1/2 hours into treatment. Treatment was discontinued and pt sent to er for eval. Pt was admitted to the hosp and chest pain attributed to hemolysis. The pt was successfully dialyzed in the hosp acute facility three days later, but expired one day later, after a cardiac arrest. Nurse mgr stated the c3 delivery system was disinfected with actril cold sterilant in the evening, five days earlier and the actril rinsed from the delivery system and removal verified using an actril residual test strip on the morning of the following day. Nurse mgr further reported, the container of actril residual test strips used during treatment were tested after pt was hospitalized using the qc protocol printed on the directions for use and found to be accurate and within acceptable standards. Facility turns on and rinses all delivery systems at the beginning of the treatment day, regardless of the scheduled first treatment for each machine. The c3 on which the pt dialyzed rinsed for approx 4-5 hours before pt was initiated on dialysis. Nurse mgr and dialysis biomed tech twice tested delivery system to verify residual actril levels at 5 and 18 minutes. Results: 5 min = all but small amount cleard, 18 min = rinsed free of actril to "0" ppm. Since pt began treatment on 2nd shift of pts, c3 had been rinsing at least 360 minutes prior to initiation of treatment. Mfr tested actril residual test strips from inventory and found strips to be within specification. Mfr believes test strips not a contributing factor.
Patient Sequence No: 1, Text Type: N, H10