ONESTEP

Description of Event or Problem

INCIDENT OCCURRED [REDACTED] IN THE ED [EMERGENCY DEPARTMENT]. PATIENT WAS IN UNSTABLE SVT [SUPRAVENTRICULAR TACHYCARDIA] IN THE 210 RATE. TRANSLUCENT PAD 8900-004041-01 APPLIED FIRST, BUT REMOVED DUE TO A STAFF MEMBER SAYING IT WAS THE WRONG PAD. THE ONE STEP PAD 8900-0224-01 WAS THEN APPLIED AND STAFF DELIVERED FIRST CARDIOVERSION. A SECOND CARDIOVERSION DELIVERED AND ARC'D. BURNS NOTED TO PATIENT'S CHEST AND PAD WAS REMOVED. A TRANSLUSCENT PAD WAS APPLIED FOR THE THIRD CARDIOVERSION. NO RHYTHM CHANGED AND REQUESTED CONSULT TO CARDIOLOGY. PATIENT RECEIVED SEDATION FOR CARDIOVERSIONS WHILE AWAITING CARDIOLOGY TEAM (5-15 MINUTES). PATIENT CODES AND A ONE STEP PAD WAS APPLIED. CPR STARTED ON FEEDBACK PORTION OF PAD. TECH REPORTS THAT IT WAS SLIDING SO HE REMOVED THE "PUCK."