Stomach rupture by infusion pump and Foley catheter
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A surgical error involving a Foley catheter led to a nine-month-old infant
Area of Science:
- Pediatric surgery
- Medical device safety
- Gastrointestinal surgery
Background:
- Esophageal atresia repair requires careful postoperative management.
- Gastrostomy tubes are common for feeding access in infants.
Observation:
- A clear adapter created confusion between catheter ports.
- Poor lighting and equipment malfunction contributed to the error.
Findings:
- Infusion pump connected to the wrong port caused gastric rupture.
- Foley catheter's balloon port was mistakenly used for drainage.
Implications:
- Highlights the need for clear medical device labeling.
- Emphasizes improved training and environmental checks in pediatric care.
- Underscores the importance of functional safety alarms in infusion pumps.
Abstract:
A nine-month-old girl who had successfully undergone surgery for esophageal atresia sustained a rupture of the stomach when an infusion pump was inadvertently connected to the balloon port of a Foley catheter being used as a gastrostomy tube. A strong similarity in appearance and feel of the balloon port and the drainage port of the catheter was created when a clear plastic adapter was inserted in the drainage port for connection of the pump tubing. Other factors contributing to the accident were poor lighting at the time of the connection, failure of the infusion pump occlusion alarm to activate at pressures low enough to prevent injury, and the reduced size of the child's stomach following surgery.