Description of Event or Problem · 1
AS THE PATIENT WAS BEING TRANSFERRED FROM THE WHEELCHAIR TO THE BED, THE FOOT REST ON THE WHEELCHAIR FELL. THE PATIENT'S LEG/FOOT CAUGHT ON THE FALLEN FOOT REST, PATIENT EXAMINATION REVEALED AN ABRASION AND DISCOLORATION ON HER RIGHT LEG AND SUBSEQUENT X-RAYS REVEALED A FRACTURE OF THE RIGHT TIBIA AND FIBULA. EVALUATION OF THE WHEELCHAIR REVEALED A LOOSE CONNECTION ON THE FOOT REST.DEVICE NOT LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: FAIR CONDITION. THERE WAS NOT MULTIPLE PATIENT INVOLVEMENT.DEVICE SERVICED IN ACCORDANCE WITH SERVICE SCHEDULE. DATE LAST SERVICED: 01-DEC-91. SERVICE PROVIDED BY: OTHER. SERVICE RECORDS NOT AVAILABLE.NO IMMINENT HAZARD TO PUBLIC HEALTH CLAIMED. DEVICE USED AS LABELED/INTENDED.DEVICE WAS EVALUATED AFTER THE EVENT. METHOD OF EVALUATION: ACTUAL DEVICE INVOLVED IN INCIDENT WAS EVALUATED, MECHANICAL TESTS PERFORMED. RESULTS OF EVALUATION: MECHANICAL PROBLEM, TELEMETRY FAILURE, NONE OR UNKNOWN. CONCLUSION: DEVICE FAILURE OCCURRED BUT NOT RELATED TO EVENT, DEVICE FAILURE DIRECTLY CAUSED EVENT. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: YES. CORRECTIVE ACTIONS: DEVICE REPAIRED AND PUT BACK IN SERVICE, INSERVICED BY OTHER FACILITY STAFF. INVALID DATA - ON DEVICE DESTROYED/DISPOSED OF STATUS.