Cause of Device-Related Incident
Support system failures

Clinical Specialty or Hospital Department
CCU / ICU / NICU; CSR / Materials Management; Nursing; Pediatrics

Device Factors
*Not stated

Document Type
Hazard Reports

External Factors
*Not stated

Mechanism of Injury or Death
Suffocation

Support System Failures
Use of inappropriate devices

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated

UMDNS
Intravenous Extension Tubing Kits [12-170]

Danger from Removable IV Extension Tubing Slide Clamps



Hazard [Health Devices Dec 1993;22(12):593]

Problem

A removable slide clamp from an intravenous (IV) extension tubing set being used on a pediatric patient was found in the patient's crib by his mother. There was concern that the clamp may pose a risk of choking.

Recommendation

In a pediatric setting, only IV extension sets with nonremovable slide clamps or without slide clamps should be used.

UMDNS Term

Intravenous Extension Tubing Kits [12-170]

Cause of Device-Related Incident

Support system failure: Use of inappropriate devices

Mechanism of Injury or Death

Suffocation


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