Description of Event or Problem · 1
A LARGE FEMALE PATIENT WAS LYING ON A BRAND NEW PROCEDURE TABLE AND ALL RADIOGRAPHIC EQUIPMENT WAS CLEAR OF THE AREA, POST-PROCEDURE. IN ORDER TO PREVENT HER ARMS FROM HANGING OVER EACH SIDE OF THE TABLE, A PAIR OF BRAND NEW ACRYLIC ARM SUPPORTS WERE PLACED UNDER A BRAND NEW MATTRESS FOR EACH ARM. THE ACRYLIC ARM RESTS WERE PURCHASED WITH THE SHIMADZU SYSTEM AND ARE SUPPOSEDLY DESIGNED FOR USE WITH THIS TABLE. AS THE PATIENT WAS TURNED TO HER SIDE TO FACILITATE A LATERAL MOVE TO A STRETCHER, THE MATTRESS BENEATH HER SUDDENLY SLID OFF THE TABLE. LUCKILY, A NURSE AND A TECH WERE ABLE TO GAIN CONTROL AND LOWER HER APPROXIMATELY THREE FEET TO THE FLOOR IN A SHEET THAT CONTAINED HER. UPON INVESTIGATION, IT WAS APPARENT THAT THE MATTRESS LOST ITS ABILITY TO GRIP THE TABLE AFTER THE ACRYLIC LIFTS, DESIGNED FOR USE SPECIFICALLY WITH THIS TABLE, WERE PLACED UNDER THE MATTRESS. THE WIDTH OF THE TABLE IS 70 CM AND THE WIDTH OF EACH ARM REST IS 25 CM. THEREFORE, LESS THAN 30% OF THE MATTRESS IS AVAILABLE TO GRIP THE TABLE TOP WHEN THE LIFTS ARE USED, WHICH IS NOT ENOUGH SURFACE AREA TO PREVENT SLIPPAGE. IT WAS EASILY DUPLICATED SEVERAL TIMES AFTERWARD IN A CONTROLLED ENVIRONMENT. AS A RESULT OF THIS INCIDENT, ALL STAFF MEMBERS WERE IN-SERVICED ON THE POTENTIAL FOR HARM, AND CURRENT PROCEDURES HAVE BEEN MODIFIED SO THAT NO PATIENT CAN BE TURNED, MOVED, ETC. UNTIL THE ARM RESTS HAVE BEEN REMOVED TO PREVENT ANY FUTURE MISHAPS. ADDITIONALLY, IT WAS REQUESTED THAT THE MANUFACTURER SUPPLY MATERIAL IDENTICAL TO THE MATTRESS. THE PLAN IS TO ATTEMPT TO AFFIX THIS MATERIAL TO THE ACRYLIC RESTS IN ORDER TO PROVIDE ADDITIONAL GRIP TO THE TABLE WHEN THE ARM RESTS ARE IN PLACE. ARMRESTS ARE RADIO TRANSLUCENT SO IT IS IMPORTANT THAT ANY MATERIAL THAT IS ATTACHED TO THE REST MUST MEET THIS CRITERIA. SINCE THIS MATERIAL WILL BE IDENTICAL TO THE CURRENT MATTRESS, IT MAY SOLVE THE PROBLEM.