Description of Event or Problem · 0
DURING POST OPERATIVE RECOVERY FROM BRAIN SURGERY STAFF WAS INSTRUCTED TO MAKE MEASUREMENTS OF THE PATIENTS OPEN EYE EVERY TWO HOURS THROUGH THE NIGHT. THE STAFF WAS INSTRUCTED TO USE A VIP-300 MEDICAL DEVICE MANUFACTURED BY NEUROPTICS TO MAKE THE MEASUREMENTS. THE DEVICE IS NOT DESIGNED TO TOUCH THE CORNEA OR SKIN AROUND THE EYE, BUT IN USE THE SURGERY STAFF SOMETIMES HOLDS THE EYELID OPEN TO OBTAIN A MEASUREMENT, PARTICULARLY AT NIGHT WHEN THE PATIENT IS SLEEPING. ON THIS NIGHT THE STAFF MEMBER HELD THE EYE OPEN TO OBTAIN A MEASUREMENT AND THE PATIENT FELT THE STAFF MEMBER TOUCH THE ANGLE OF THE EYE. IN A FEW MINUTES THE PATIENT REPORTED TO THE STAFF MEMBER THAT HIS LEFT EYE WAS ITCHING. HE ASKED IF THE STAFF MEMBER COULD FLUSH HIS EYE WITH A EYE WASH CUP. THE STAFF MEMBER REPORTED NO EYE FLUSH WAS AVAILABLE. THE PATIENT MANAGED TO OBTAIN A BOTTLE OF STERILE WATER FROM THE STAFF MEMBER AND PAPER CUP, AND TRIED TO CONFORM THE CUP TO FIT THE PATIENTS LEFT EYE SOCKET, FILLING THE CUP AND SPLASHING STERILE WATER ON THE EYE AND FACE. THE PATIENTS LEFT EYE CONTINUED TO ITCH. THE NEXT DAY A TEAM OF NURSING STAFF MEMBERS VISITED THE PATIENT AFTER HEARING THAT THE PATIENT COMPLAINED TO THE MEDICAL DEVICE MAKER ON THE THEIR WEBSITE THAT NIGHT ABOUT THE DANGEROUS DESIGN OF THE INSTRUMENT INSTRUCTIONS. THE PATIENT ASSURED THE STAFF THAT HE FELT HE WAS RECOVERING. THE FOLLOWING DAY AFTER THE PATIENT WAS RELEASED, THE PATIENT BEGAN TO EXPERIENCE SWELLING IN HIS LEFT EYE. HE WAITED ANOTHER DAY TO OBSERVE THE SWELLING AND IT WAS MORE PRONOUNCED. THE PATIENT WENT TO AN URGENT CARE FACILITY AND WAS DIAGNOSED WITH AN INFECTION IN HIS LEFT EYE, AND HE WAS PRESCRIBED ANTIBIOTICS. THE PATIENT IS NOW ON A 7 WEEK COURSE OF ANTIBIOTICS.