TRENDELENBURG POSITIONING KIT

Description of Event or Problem

PATIENT WAS PLACED IN THE DORSAL LITHOTOMY POSITION WITH LEGS IN ALLEN STIRRUPS WITH CARE TAKEN TO AVOID NERVE INJURY. HOWEVER, ON MOVING THE BED INTO REVERSE TRENDELENBURG THE PATIENT SLIPPED ON THE POSITIONING PAD CAUDAD SIGNIFICANTLY, LEADING TO IMMEDIATE DISCONTINUATION OF THE CASE AND SAFE REPOSITIONING OF THE PATIENT ON THE BED.