REICHERT/CAMBRIDGE

Description of Event or Problem

THE PATIENT WAS SEATED UPRIGHT IN THE OPHTHALMOLOGY CLINIC EXAMINATION CHAIR. THE SLIT LAMP MICROSCOPE TABLE WAS PLACED OVER THE PATIENT'S LEGS BY THE PHYSICIAN IN PREPARATION FOR AN EYE EXAMINATION. THE PHYSICIAN PUSHED THE BUTTON ON THE OPHTHALMIC CONSOLE/INSTRUMENT STAND IN ORDER TO RAISE THE CHAIR TO THE LEVEL NEEDED FOR THE EXAM. THE CHAIR BEGAN TO RISE. THE CHAIR CONTINUED TO RISE DESPITE THE PHYSICIAN HAVING RELEASED THE BUTTON. THE PATIENT'S THIGH WAS PINNED BETWEEN THE CHAIR AND THE SLIT LAMP TABLE. A TECHNICIAN IN THE ROOM UNPLUGGED THE ELECTRICAL CORD THAT WAS CONNECTED TO THE CHAIR VIA A RELAY BOX FROM THE CONSOLE/STAND. THE CHAIR STOPPED RISING. THE TECHNICIAN THEN PLUGGED THE CORD BACK IN, THE PHYSICIAN PUSHED THE BUTTON FOR THE CHAIR TO LOWER. THE CHAIR LOWERED, RELEASING THE PATIENT'S LEG.