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