Description of Event or Problem · 1
THERE WERE TWO DEVICE-RELATED OCCURRENCES OF THE KING VISION PORTABLE VIDEO LARYNGOSCOPE IN A THREE-DAY PERIOD. THE FIRST OCCURRENCE WAS THAT THE CREW MEMBER ATTEMPTED TO USE THE KING VISION TO INTUBATE A PATIENT AND OBSERVED THAT THE BATTERY COMPARTMENT COVER WAS OFF. THE CREW MEMBER PLACED THE COVER BACK ON AND THE SCOPE WOULD NOT TURN ON. THE SCOPE WAS SET ASIDE AND INTUBATION WAS COMPLETED WITH STANDARD LARYNGOSCOPE. THERE WAS NO ADVERSE OUTCOME TO THE PATIENT. FOLLOW UP: ONE OF THE THREE BATTERIES HAD BEEN PLACED IN THE WRONG DIRECTION. EXPERIENCED STAFF INDICATED CONTRIBUTING FACTORS TO BE POOR EQUIPMENT DESIGN, EXCESSIVE DISTRACTIONS AND HASTE. ON A DIFFERENT DAY, THE KING VISION WAS FOUND TO BE INOPERABLE DURING THE TREATMENT OF A MULTI-TRAUMA PATIENT. THERE WAS ANOTHER KING VISION AVAILABLE ON A SECOND RIG THAT WAS AT THE SCENE AND SO THAT ONE WAS USED TO INTUBATE THE PATIENT. THE NON-OPERATIONAL SCOPE WAS PULLED FROM SERVICE. INSPECTION OF THE DEVICE REVEALED THAT THE BATTERIES WERE INCORRECTLY INSERTED AND THAT IS WHY THE UNIT DID NOT WORK. EXPERIENCED STAFF LISTED CONTRIBUTING FACTORS AS BEING A POOR EQUIPMENT DESIGN, EXCESSIVE DISTRACTION AND HASTE.FURTHER FOLLOW UP: CHANGING BATTERIES IN THE DEVICE WAS PART OF THE TRAINING, BUT THE DEVICE IS NOT USED FREQUENTLY AND SO STAFF MAY BE NOT RECALL THE CORRECT STEPS.THE BLACK STRIP (RIBBON) MUST BE PLACED PROPERLY UNDER ALL THREE BATTERIES (3 AAA SIZE ALKALINE BATTERIES) TO ASSURE EASE OF REMOVAL. STAFF HAVE EXPERIENCED PROBLEMS WITH THE BLACK STRIP AND HAVE FOUND THAT IF IT IS JUST PUSHED DOWN, THE BATTERIES MAY NOT MAKE CORRECT CONTACT AND THAT THE BOTTOM BATTERY HAS TO GET DUG OUT. ALSO, IF THE BATTERIES ARE NOT IN PROPER PLACE, THE COVER IS HARD TO OPEN. IT WAS REPORTED THAT SOME STAFF ARE USING A COIN TO OPEN THE COMPARTMENT WHEN IT IS DIFFICULT TO OPEN. STAFF INVOLVED RECEIVED FOLLOW UP AND TRAINING. THIS DEVICE IS NOT NEW TO THIS FACILITY.