100 UNITS/ML, 5ML FILL IN 12 ML SYRINGE MEDEFIL

ON (B) (6) 2010, A NURSING UNIT VOICED A COMPLAINT TO THE PHARMACY THAT IT WAS HAVING PROBLEMS WITH THE FLUSH SYRINGES. IT SEEMS THAT AFTER THE NURSE CONNECTS THE LUER LOCK TO THIS PORT AND DRAWS BACK FOR BLOOD RETURN, THE NURSE GETS A SYRINGE FULL OF AIR. IT SEEMS THAT THE LUER LOCK IS NOT A COMPLETELY CLOSED SYSTEM, THAT IT IS NOT AN "AIR-TIGHT" SYSTEM. NURSING EDUCATOR DETERMINED THAT IT WAS PROBABLY A PRODUCT PROBLEM AND NOT A NURSING TECHNIQUE ISSUE. UPON FURTHER QUESTIONING OF OTHER NURSING STAFF, IT WAS DETERMINED THAT THE PROBLEM STARTED WHEN THE PHARMACY CHANGED MFRS FOR THE FLUSH SYRINGES. THIS CHANGE OCCURRED IN (B) (6) 2009. PER NURSING STAFF, IT IS A CONSISTENT PROBLEM AND DOES NOT SEEM TO BE RELATED TO A SPECIFIC LOT NUMBER. MEDEFIL INC. WAS CALLED TO SEE IF THERE WERE ANY OTHER REPORTS OF PROBLEM. WAS TOLD THAT IT WAS A TECHNIQUE ISSUE -NURSING NEEDED TO PULL STRAIGHT BACK, NOT AT AN ANGLE. A NURSING REP FROM MEDEFIL WAS SUPPOSED TO CALL REGARDING INSERVICING OF NURSES, BUT REP HAS NOT CALLED BACK TO DATE. BEFORE THE CHANGE IN (B) (6) 2009, THE PHARMACY STOCKED THE EQUIVALENT PRODUCT FROM (B) (4). OUR INSTITUTION DID NOT HAVE THESE ISSUES WITH THE (B) (4) PRODUCT. OUR INSTITUTION HAS NOW SWITCHED BACK TO THE (B) (4) PRODUCTS. DATES OF USE:(B) (6) 2009 - (B) (6) 2010. DIAGNOSIS OR REASON FOR USE: FLUSHING OF CENTRAL LINE.