Description of Event or Problem · 1
A PERCUTANEOUS NEPHROLITHOTRIPSY WAS PERFORMED. DURING THIS PROCEDURE SALINE SOLUTION IS FLUSHED INSIDE THE KIDNEY WHILE FIBEROPTICS IS USED TO LOCATE THE KIDNEY STONE. ONCE THE STONE IS LOCATED AN ULTRASONIC LITHOTRIPTOR IS USED TO SMASH THE STONE AND WITHDRAW THE FRAGMENTS VIA SUCTION. SEVERAL HUNDRED MILLILITERS OF SALINE ARE USED FOR EACH EXAMINATION, THE MAJORITY OF WHICH IS COLLECTED AND DISPOSED OF; HOWEVER, WITH THE USE OF SEVERAL DIFFERENT INSTRUMENTS, SOME SALINE IS INADVERTENTLY SPILLED UPON THE FLOOR. THE X-RAY TUBE HEAD IS COVERED WITH A PLASTIC BAG DURING THESE PROCEDURES SO AS TO KEEP THE SALINE SOLUTION FROM ENTERING THE COLLIMATOR. DURING THIS EXAMINATION, WHILE MOVING THE TABLE IN DIFFERENT POSITIONS, THE BAG SLIPPED OFF OF THE COLLIMATOR, ALLOWING SOME OF THE SALINE TO HIT THE COLLIMATOR RESULTING IN SEEPAGE WITHIN. WHEN THE ROOM WAS USED THE FOLLOWING DAY FOR AN ARTERIOGRAM, PART OF THE MANUAL BOLUSING WAS INOPERATIVE. SERVICE INSPECTION FOUND THAT SALINE WAS READILY APPARENT AND HAD COME WITHIN INCHES OF HIGH TENSION WIRING (70,000 - 100,000 VOLT) THAT COULD HAVE RESULTED IN FATALITIES. THE COLLIMATOR HEAD WAS REPAIRABLE AND FURTHER PROCEDURES LIKE THESE HAVE BEEN DISCONTINUED; HOWEVER, CONCERN HAS BEEN RAISED ABOUT PROCEDURES THAT ARE NECESSARY IN THE ANGIO SUITE THAT ALSO HAVE FLUID PRESENCE (IE. BLOOD, STERILE WATER, ETC.).