How medical device failures cause patient injuries

An EMS crew is transporting a 28-year-old pregnant patient to a high-risk labor and delivery unit. She will be a direct admission with a diagnosis of premature labor.

She has an IV pump running with normal saline and magnesium. During the transport, the IV pump's alarm continues to sound with multiple error messages. The attending paramedic attempts to troubleshoot the problem without success. Finally, the attendant shuts off the pump and the IV is maintained at a keep open rate.

The patient's labor intensifies and upon arrival at the hospital the crew is questioned by the receiving staff about shutting off the pump. The attending physician believes the device failure and subsequent decisions directly affected the patient's labor.

Alex Christgen, Project Manager at the Center for Patient Safety, states "health care has seen an influx of new technology and new devices, as well as improvements to current devices. Many of these innovations have improved the quality and safety for the patient and eased the workload for the provider, but as with any tool these devices may have weak points or may not be implemented into the system as expected."

Medical device adverse events
The CPS Patient Safety Organization receives regular reports of device failures. These range from operational error to the actual device failing during operation. These failures can be linked to a variety of factors.

Some of the most common factors include improper usage or stressing a device beyond its recommendations. Other reports include battery or power failure which is critical for many devices to function.

Stretcher drops and tips
Another common scenario that can happen anywhere: A crew reports placing a patient on the stretcher with three belts and shoulder straps and then moving the stretcher to the ambulance. The paramedic asks other providers at the scene to help load the patient and operate the stretcher.

The other providers agree to assist; one takes position at the head and another at the foot of the stretcher. The paramedic goes ahead of them to the front door of the home to open and hold the screen door. The other providers have not been fully trained on the stretcher including how to use the motorized lift, so they raise it to the high load position. While navigating the doorway they encounter an uneven surface area on the front porch.

The stretcher becomes top heavy and overturns. They try to quickly recover and slow the fall; however, the patient is injured in the fall.

Moving and lifting patients has inherent risks to the patient and provider. This includes stretcher related events where either a patient or provider is injured. Reports of stretchers tipping over and failing during the loading or unloading from the ambulance are not uncommon.

The causes for these events vary; however, common factors include inattention, over stressing the stretcher and lack of training. Due to the often extreme conditions and often unpredictable environment that EMS operates in, stretchers may be placed in situations where they can injure a provider and patient due to a failure.

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