jueves, 11 de diciembre de 2014

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web ► Medical Devices in the "Wild" Commentary by Ayse P. Gurses, PhD, and Peter Doyle, PhD

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web

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Medical Devices in the "Wild"
Commentary by Ayse P. Gurses, PhD, and Peter Doyle, PhD

The Case

A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes, chronic pain, arthritis, and hyperlipidemia was admitted to the hospital with a CHF exacerbation manifesting as lower extremity edema and weight gain. At baseline, he was able to function independently and perform all activities of daily living. The patient was treated with diuretics, fluid restriction, and was given dietary and medication education. After a short period of treatment, his swelling improved and he was able to ambulate on the hospital ward without difficulty. The medical team was preparing the patient for discharge the following day.

That afternoon, the patient was lying in bed watching television when his nurse came into the room to assess him. The bed was low to the ground and locked in position, so she raised the bed up to perform her assessment. The patient had sequential compression devices (SCDs) in place to prevent deep venous thrombosis (DVT). When the nurse raised the bed, unbeknownst to her, the tubing for the SCDs caught on the bed wheel lock and unlocked the bed. After completing her assessment, the nurse left the room. Having been told he should ambulate several times daily, the patient then sat up on the side of the bed and attempted to stand. In doing so, he pushed down on the bed with his hands. When he did this, the bed rolled out from under him and he fell onto his left side. He immediately complained of hip pain, and on radiographs was found to have a broken left hip.

The next day he went to surgery for planned open reduction and internal fixation of his hip fracture. Unfortunately, he developed respiratory issues and had to be transferred to the medical intensive care unit for closer monitoring postoperatively. He did improve temporarily, but despite receiving appropriate DVT prophylaxis, one week after surgery he suddenly experienced a cardiac arrest and was found to have a massive pulmonary embolism. He was briefly resuscitated but died a short time later.

The unit where the fall occurred called a multidisciplinary "fall huddle" to reenact the circumstances of the incident. The nurse was certain the bed was locked, but a technician noticed that the SCD tubing had fallen around the wheel and brake of the bed. During the reenactment, the staff realized it was possible for the tubing to catch the brake and unlock the bed without being noticed. The hospital's patient safety department immediately informed the company that manufactured the beds and the SCD equipment. The SCDs were replaced with newer equipment that had shorter tubing that could not wrap around the bed brake and unlock it inadvertently.

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