Description of Event or Problem · 0
THE HOSPITAL HAS HAD CONTINUAL PROBLEMS WITH OUR MINI-C ARM. BOTH OPERATIONALLY AND WITH IMAGE QUALITY. THESE CHALLENGES HAVE LED TO INCREASED SURGICAL TIME AND INCREASED NUMBER OF IMAGES TAKEN TO FIND A USABLE IMAGE FOR A PATIENT UNDERGOING SURGERY. THIS CONCERN HAS BEEN ESCALATED TO THE DEVICE MANUFACTURER MULTIPLE TIMES. ULTIMATELY, THIS RESULTED IN THE COMPANY BRINGING THE HOSPITAL AN UPGRADED NEWER MACHINE, HOWEVER WE HAVE CONTINUED TO EXPERIENCE SIMILAR PROBLEMS. THE PERFORMANCE CONCERNS HAVE NOT BEEN SATISFACTORILY ADDRESSED BY THE VENDOR. WE WERE RECENTLY GIVEN A SOFTWARE UPGRADE THAT WAS SUPPOSED TO CORRECT SOME OF THE CONCERNS, AND IT HAS NOT SATISFACTORILY DONE SO. AN ADDITIONAL CHALLENGE WITH THIS MACHINE IS AS FOLLOWS: THE TIMING OF THE INITIATION OF THE X-RAY HAS TO BE PERFECT. HISTORICALLY, OUR PREVIOUS MACHINE WORKED WELL, ONE COULD TAP THE PEDAL AND YOU WOULD GET A GOOD IMAGE. WITH THIS MACHINE, YOU HAVE TO PRESS AND HOLD THE PEDAL BUTTON ON THE SIDE OF THE MACHINE FOR THE PERFECT AMOUNT OF TIME FOR IT TO FOCUS. IF YOU DON'T HOLD IT LONG ENOUGH, YOU GET A GRAINY UNUSABLE IMAGE. IF YOU HOLD IT TOO LONG, IT SWITCHES TO LIVE FLUOROSCOPY. THE VENDOR EXPLAINS THIS IS THE WAY IT IS DESIGNED; NO ADJUSTMENTS CAN BE MADE TO IMPROVE THIS SITUATION. THE END RESULT IS THAT THE OR TEAM ENDS UP TAKING MANY MORE IMAGES THAN NECESSARY AND INCREASES THE SURGICAL TIME AND SURGEON FRUSTRATION. THE PEDAL IS MORE CHALLENGING TO OPERATE SO THE TEAM TYPICALLY USES THE BUTTON. THE PROBLEM WITH THIS IS IT IS EXTREMELY CHALLENGING TO GET TO THE BUTTON IN HAND CASES. THE STAFF RUN THE RISK OF BUMPING THE MACHINE WHICH WOULD BLUR THE IMAGE, CONTAMINATING THE DRAPE OR THEMSELVES. IT IS EXTREMELY CHALLENGING TO MAINTAIN GOOD ERGONOMICS AND THE TEAM IS PUT AT RISK FOR INJURIES PARTICULARLY THE SCRUB NURSE WHO IS TRYING TO OBTAIN THE IMAGE. THE SURGEON AND RESIDENT ARE HOLDING THE LIMB BECAUSE THE EXTREMITY HAS TO BE HELD PERFECTLY STILL TO GET A USABLE IMAGE. WE HAVE ESCALATED THIS CONCERN TO OUR RADIOLOGY LEADERS AND HAVE ASKED FOR A REPLACEMENT. IN THIS PARTICULAR EVENT, THE ORTHO SURGEON WAS IN THIS PROCEDURE WITH AN OPEN REDUCTION AND INTERNAL FIXATION OF LEFT SCAPHOID FRACTURE WITH LEFT DISTAL RADIUS CANCELLOUS BONE GRAFT. THE SURGEON START TIME WAS 1519 AND STOP TIME WAS 2053. THE LENGTH OF THE PROCEDURE WAS NEGATIVELY IMPACTED BY THE FUNCTIONALITY CHALLENGES OF THE ORTHOSCAN. THE PATIENT DID NOT EXPERIENCE HARM OR INJURY FROM THIS EVENT.