VITAL VUE

Description of Event or Problem

DURING THE CASE THE VITAL VUE SUCTION WAS GIVEN TO THE STERILE FIELD. A ONE LITER BAG OF SALINE WAS SPIKED AND THE TUBING WAS ATTACHED TO THE SUCTION MACHINE. THE SURGEON DRAPED THE SUCTION OVER THE PATIENTS RIGHT THIGH AS IT WAS USED INTERMITTENTLY THROUGHOUT THE CASE. WHEN HOOKING UP THE LIGHT SOURCE FOR THE CYSTOSCOPY THE NURSE NOTED THE VITAL VUE WAS DRAPED OVER THE PATIENTS LEG AND ASKED THE SURGEON IF THE VITAL VUE WAS ON. THE RESIDENT RESPONDED NO, BUT DID NOT MOVE OR CHECK IF THE LIGHT WAS ON. THE NURSE UNPLUGGED THE TUBING FROM THE VITAL VUE AT THAT TIME AND THE CASE PROCEEDED. AT THE END OF THE CASE THE DRAPES WERE REMOVED FROM THE PATIENT AND THE NURSE NOTED A RAISED REDDENED AREA WITH BLISTERS ON THE PATIENTS RIGHT INNER THIGH NEAR THE BOVIE PAD SITE. THE BOVIE PAD WAS REMOVED. THE SITE WAS UNCHANGED; NO REDNESS, SWELLING, OR SKIN CHANGES.