Education

Case serial: SCH-2021-01
Title: Silicon Levin tube, 14FR

Description

Patient Condition

  • A 45-year-old female patient was inserted with a 14Fr Levin tube in the intensive care unit. As the patient was thin, the physician selected a 14Fr tube rather than a 16Fr tube.
  • To check that the Levin tube was located inside the stomach, the physician put air in using a syringe and subsequently observed with a stethoscope.
  • To double-check that the Levin tube was properly placed in the patient's stomach, a chest X-ray was taken.

Events

  • The radiologist failed to find the Levin tube from the patient's chest X-ray image. Refer to Figure (a).
  • Normally, the Levine tube would be observed in the chest X-ray image as shown in Figure (b).

Post-event management & Health effect

  • Removed the Levin tube for patient safety and inserted another 14Fr tube.
  • The patient retook a chest X-ray to check for the right placement of the Levin tube.
  • The patient expressed discomfort in the nose area due to repeated insertion.

Investigations (Cause, Improvements)

  • Quality manager of the manufacturer detected that the radio-opaque line impregnated was narrower in width and contained smaller amount of barium sulfate at the tip, compared to the Levin tube of the same lot.
  • The manufacturer decided to increase the width of the radio-opaque line to 8 mm for the Levin tube.

Click to Zoom

Annex

Code

#

%

A A01 - Lower Level Codes 27 25.0%
A A02 - Lower Level Codes 27 25.0%
A A03 - Lower Level Codes 12 11.1%
A A04 - Lower Level Codes 10 9.3%
A A06 - Lower Level Codes 6 5.6%
A A05 , A15 , A23 , A07 , A24 , A26 , A20 , A27 , A08 , A09 , A17 , A19 , A21 26
total:108
24.1%
B B01 - Lower Level Codes 23 34.8%
B B02 - Lower Level Codes 17 25.8%
B B03 - Lower Level Codes 10 15.2%
B B04 - Lower Level Codes 4 6.1%
B B12 - Lower Level Codes 3 4.5%
B B07 , B14 , B21 , B13 , B05 , B06 9
total:66
13.6%
C C06 - Lower Level Codes 27 45.8%
C C16 - Lower Level Codes 9 15.3%
C C01 - Lower Level Codes 5 8.5%
C C09 - Lower Level Codes 4 6.8%
C C07 - Lower Level Codes 4 6.8%
C C22 , C13 , C14 , C17 , C03 , C04 , C08 10
total:59
16.9%
D D01 - Lower Level Codes 21 37.5%
D D03 - Lower Level Codes 21 37.5%
D D02 - Lower Level Codes 5 8.9%
D D15 - Lower Level Codes 2 3.6%
D D04 - Lower Level Codes 2 3.6%
D D10 , D11 , D16 , D18 , D09 5
total:56
8.9%
E E24 - Lower Level Codes 13 23.2%
E E01 - Lower Level Codes 7 12.5%
E E07 - Lower Level Codes 7 12.5%
E E21 - Lower Level Codes 6 10.7%
E E10 - Lower Level Codes 6 10.7%
E E23 , E17 , E20 , E22 , E03 , E14 , E18 , E02 17
total:56
30.4%
F F05 - Lower Level Codes 12 20.7%
F F11 - Lower Level Codes 9 15.5%
F F26 - Lower Level Codes 6 10.3%
F F01 - Lower Level Codes 5 8.6%
F F04 - Lower Level Codes 3 5.2%
F F06 , F10 , F14 , F19 , F16 , F18 , F07 , F22 , F08 , F23 , F24 , F12 , F13 , F02 , F03 , F15 23
total:58
39.7%
G G01 - Lower Level Codes 14 26.4%
G G03 - Lower Level Codes 10 18.9%
G G04 - Lower Level Codes 9 17.0%
G G05 - Lower Level Codes 8 15.1%
G G07 - Lower Level Codes 8 15.1%
G G02 , G06 4
total:53
7.5%

X-ray after Levin tube is inserted into the patient's chest

Ju min Park , Republic of Korea
[ 2021-09-01 13:42:08.0]

Is the method of applying IMDRF in this study correct because visible light is emitted during X-ray imaging?

[6]

Material integrity problem

Soo Jeong Choi , Republic of Korea
[ 2021-09-01 17:37:06.0]

Concept of material integrity is not easy for me. I wonder the correct code.

[5]

Wonderful case.

Soo Jeong Choi , Republic of Korea
[ 2021-09-01 17:50:49.0]

This case made me thinking! This case is very educated!

[6]

Very Educational program

Jieun Lee , Republic of Korea
[ 2021-09-10 09:18:30.0]

Thank you so much :)

[3]

Levin tube

María Eugenia Villalobos-Hernández , (Non-APEC) Costa Rica
[ 2021-09-10 10:57:44.0]

This case refers to a real probability that may occur

[3]
You Kyoung Lee , Republic of Korea [ 2021-09-10 14:46:13.0]

Agreed. It happens.

Levin tube

Jaeyeong Jang , Republic of Korea
[ 2021-09-11 10:46:09.0]

this case is interesting because of its clinical probability.

[3]
Jin Kuk Kim , Republic of Korea [ 2021-09-12 12:13:22.0]

Agreed. It's already happens

Levin tube

María Eugenia Villalobos-Hernández , (Non-APEC) Costa Rica
[ 2021-09-12 02:20:41.0]

It is very important to analyze any case using the IMDRF codes, therefore it is useful to have a integrated perspective of the event

[1]

Levin tube procedure

Jin Kuk Kim , Republic of Korea
[ 2021-09-12 12:09:14.0]

Levin tube insertion is mainly done by intern in Korea. In this situation, the intern is very embarrassed because he can't check the Levin tube on X-ray.

[1]

Levin Tube

JooMyung Song , Republic of Korea
[ 2021-09-12 21:26:15.0]

This is beneficial trial to have skillset to select proper answer of adverse event reporting in IMDRF

[1]

Levin Tube

Ji hyun Kim , Republic of Korea
[ 2021-09-13 14:39:47.0]

This case was very interesting during the conduct as it was very likely to happen in the clinical area.

[1]

Silicon Levin tube, 14FR

Jiyun Jeong , Republic of Korea
[ 2021-09-13 15:32:17.0]

Chemical Problem

[1]

Levin tube

Pei-Hsuan Huang , The United States
[ 2021-09-14 04:25:26.0]


Chemical Problem

[1]

Silicon Levin tube, 14FR

Jeffrey Recustodio , The Philippines
[ 2021-09-14 11:48:59.0]

This case is a real scenario that will happen anytime.

[1]

Levin tube

SoonWoo Hong , Republic of Korea
[ 2021-09-14 12:58:55.0]

This is helpful in studying adverse event reporting of IMDRF.

[1]

Silicon Levin tube, 14FR

Stevie Lee , Republic of Korea
[ 2021-09-14 15:50:32.0]

This activity is very helpful

[1]

Silicon Levin tube

Jang Soonheung , Republic of Korea
[ 2021-09-15 11:11:13.0]

as This activity is very helpful, thamk you

[1]

Handling of the device not in accordance with specification, prior to use on the patient.

Jang Soonheung , Republic of Korea
[ 2021-09-15 11:18:04.0]

as This activity is very helpful, thank you

[1]

This is helpful in studying adverse event reporting of IMDRF.

Soohyun Nam , Republic of Korea
[ 2021-09-15 12:22:54.0]

This is helpful in studying adverse event reporting of IMDRF.

[2]

Silicon Levin tube, 14FR

Nami Migita , The United States
[ 2021-09-16 01:05:11.0]

This case is very helpful.

[2]

Levin Tube

YoonSung Kim , Republic of Korea
[ 2021-09-16 17:46:40.0]

This programe is able to make helpful in studying IMDRF.

[1]

Levin tube case

Citra Bonnita Putri , Indonesia
[ 2021-09-16 21:16:49.0]

This activity is helpful.

[1]

Health consequences

María Del Rocío Peinador Roldán , (Non-APEC) Costa Rica
[ 2021-09-16 23:15:30.0]

Discomfort can be considered "No Health Consequences or Impact"? It is a doubt that I have. Subjective (f.ex:pain) or observed (f.ex:injury)

[1]

Levin tube

Chang Hyun Lim , Republic of Korea
[ 2021-09-17 16:34:26.0]

This activity is helpful

[1]

Silicon Levin tube, 14FR

Erika Masis , (Non-APEC) Costa Rica
[ 2021-09-20 09:45:53.0]


This case is very helpful.

[2]

Silicon Levin tube, 14FR

Erika Masis , (Non-APEC) Costa Rica
[ 2021-09-20 10:15:54.0]

This case is very helpful.

[2]

Silicon Levin tube, 14FR

Erika Masis , (Non-APEC) Costa Rica
[ 2021-09-20 10:22:09.0]

This case is very helpful.

[2]

Levin tube

Jang Hyejung , Republic of Korea
[ 2021-09-20 15:33:57.0]

It's very good case.

[2]

Silicon Levin tube, 14FR

Regina Li , Hong Kong
[ 2021-09-21 11:09:43.0]

This case is very helpful.

[2]

Silicon Levin tube, 14FR

Seontae Kim , Republic of Korea
[ 2021-09-21 16:13:48.0]

Thank you and this case is helpful

[0]

This activity is helpful

Jiyeon Kin , Republic of Korea
[ 2021-09-21 23:03:10.0]

This activity is very helpful

[0]