Description of Event or Problem · 0
A VERY PREMATURE DELIVERY WAS PLANNED VIA UNSCHEDULED C-SECTION. WHILE AWAITING RECEIPT OF THE CHILD, THE INTUBATION EQUIPMENT WAS TESTED, ANTICIPATING THE NEED FOR PULMONARY SUPPORT. DISPOSABLE LARYNGOSCOPE HANDLES HAVE BEEN IMPLEMENTED. IT IS OUR PRACTICE THAT THE HANDLES ARE TESTED PRIOR TO DEPLOYMENT IN THE CODE CARTS BY THE CENTRAL STERILE TEAM. AT LEAST 6 DIFFERENT DISPOSABLE HANDLES WOULD NOT WORK. ASSUMING THE POSSIBILITY OF USER ERROR, WE DEPLOYED ADDITIONAL PERSONNEL FOR SUPPORT. SIX HANDLES WITH ATTEMPTS BY MULTIPLE EXPERIENCED NURSES, RESPIRATORY THERAPISTS, PHYSICIANS, CENTRAL STERILE TECHS (WHO TEST THESE ITEMS ROUTINELY), & OTHER OR PERSONNEL ALL WOULD NOT WORK. A REUSABLE HANDLE WAS DEPLOYED, WORKED IMMEDIATELY, & ALL RESUSCITATION EQUIPMENT WAS IN PLACE BEFORE NEEDED. ITEM WAS NOT USED ON PATIENT AND NO HARM TO PATIENT. REFERENCE REPORTS: MW5146320, MW5146321, MW5146322, MW5146324, MW5146325.