Shared on behalf of Quality and Risk Management

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Please share with applicable staff.

Thunder Bay Regional Health Sciences Centre has been alerted to issues with the Baxter Clearlink System Continu-Flo Solution Set / IV Tubing (Product Code 2C8519) where there is a potential for leaks that stem from faulty upper or lower ports/valves/claves during drug preparation or administration.

The following mitigation actions have been identified by Ontario Health (Cancer Care Ontario):

1. Remove lots R25C29185, R25C25161, R25C13147, R25C17079, R25C20130, using
   alternate product lots.
2. Check lines carefully while diluent runs prior to drug reaching the port.
3. Document IV tubing lot number and expiration date used for all infusions.
4. Monitor and periodically check port/valve/clave and connection sites during changes in
   infusion rates.

If you notice any leaking while using any lots of the Clearlink System Continu-Flo Solution Set
/IV Tubing, please take the following actions:

1. Immediately stop the infusion and replace the tubing.
2. Complete an Incident Learning System and reference the lot and expiration date of the solution set / IV tubing used.
3. Notify your Manager and provide him/her with the faulty product.

We appreciate your efforts and cooperation in these extra steps to ensure patient safety.