"Exploding" NxtStage bags

PLEASE NOTE:   Posts made to this forum should not be considered as the expressed opinions of, nor should be considered endorsed by, the Medication Safety Officer’s Society (MSOS) or the Institute for Safe Medication Practices (ISMP). 

Make sure your email is up-to-date
In order to continue to receive updates from MSOS, as well as forum posts and other valuable information as a member of MSOS, please be sure to update your email address with us, whenever it changes. If you need assistance doing so, please send an email to jrufo@ismp.org

6 posts / 0 new
Last post
Stacie Ethington
Stacie Ethington's picture
Offline
Last seen: 2 weeks 4 days ago
Joined: 12/07/2016 - 11:14
"Exploding" NxtStage bags

We have seen a trend of RFP 404 & 400 NxtStage dialysate bags either having holes in the bag once removed from outer packaging OR seams "exploding" or "popping" when the seal that separates the two compartments is broken for mixing. We have about 15 reports of this occurring over the last couple of weeks. I have reported to ISMP and we are in the process of reporting to the manufacturer. Has anyone else seen this? These are experienced ICU nurses that hare having the issue--I don't think it's training or knowledge related.

Appreciate your input,
Stacie Ethington MSN, RN
Nebraska Medicine