inforMED
MalfunctionJEA

TABLE, SURGICAL

Received Oct 7, 2015 · Event occurred Jun 25, 2015

Report 5131066 · MDR key 5131066

Device

Generic name

Table, Surgical

Product problems

  • Improper or Incorrect Procedure or Method
  • Positioning Problem

Patient

89 YR

  • No Information

Narrative

Description of Event or Problem

PATIENT WAS POSITIONED ON FRACTURE TABLE IN THE OPERATING ROOM. THE RIGHT FOOT WAS PLACED IN TRACTION BY DOCTOR, THE LEFT LEG WAS PLACED IN STIRRUP. THE CENTER OF THE FRACTURE TABLE WAS REQUESTED BY DOCTOR TO BE REMOVED. I TOLD HER THAT I WAS NOT AWARE OF THE PROCEDURE TO ACCOMPLISH HER REQUEST. DOCTOR INSTRUCTED ME TO REMOVE A PIN FROM THE FOOT OF THE TABLE, I ASKED IF SHE WAS SURE THAT THE PIN WAS VERY SECURE. SHE THEN INSTRUCTED ME TO STRAIGHTEN THE PIN RELEASE AND PULL THE PIN. I ASKED AGAIN IF SHE WAS SURE. SHE SHOWED ME THE MOTION REQUIRED. I PULLED THE PIN AND THE MAIN SUPPORT TO THE TABLE DROPPED DOWN TO THE FLOOR OF THE TABLE. SEVERAL STAFF IN THE ROOM ASSISTED IN REPLACING THE PIN.