Falls from operating table prompt new procedures at hospitals

Hey there, time traveller!
This article was published 09/02/2010 (5758 days ago), so information in it may no longer be current.

New procedures for transferring patients from the operating table to a bed are being implemented in Winnipeg hospitals after two incidents last year at Grace General Hospital.

Both cases involved patients who had just undergone orthopedic surgery.

On Dec. 24, a female patient fell to the floor as she was being transferred to a bed, sustaining a "cut on the head." She died within days of the accident, but a CT scan indicated that her death was not related to the fall, said Real Cloutier, the Grace’s chief operating officer.

No autopsy was performed, at the request of the family, he said. No staff members were disciplined because the incident was judged to be an accident.

Cloutier said the accident occurred as a nurse bent over to grab something off the floor. "The patient slipped off the table onto the nurse’s shoulder and fell to the floor."

In conducting a review of that case, as required because an injury occurred, hospital administrators learned of a near-miss involving another orthopedic patient only a month before.

In the Nov. 19 incident, the patient was "seen slipping" off the operating table after surgery and "was essentially held and lowered softly to the floor," Cloutier said. That individual — the hospital did not indicate whether the person was male or female — was uninjured so there was no critical incident report filed.

Last week, the Winnipeg Regional Health Authority said it was looking to ease the orthopedic surgery load on the Grace after 25 operations were cancelled in recent weeks due to a shortage of beds at the hospital. Three other city hospitals perform such procedures.

A hospital employee called the Free Press anonymously after that story appeared, telling of the recent incidents involving patient transfers from the operating room.

The employee alleged that the incidents occurred because the hospital is understaffed and people are working too quickly. "I think people need to slow down. People have to accept that they only have two hands," said the employee, who did not want to be identified.

Cloutier disagreed that speed or overwork were factors in the two cases, saying that in the review of the Dec. 24 incident those issues were never raised by physicians or other employees. He did agree with the employee, however, that a failure to engage a bed brake led to the first incident.

As a result of the review, the Grace and other hospitals will now ensure that patients are strapped around the torso "so there’s no potential for rapid slipping" before they are transferred from the operating table, Cloutier said. One staff member — the operating room scrub nurse — will be assigned the task of monitoring the patient just as the operation is completed and the transfer begins. And, staff will ensure that beds are locked in place.

Cloutier said that in the Christmas Eve incident, the family was immediately notified. And last week, it was given a full report on the hospital’s findings and recommendations.

larry.kusch@freepress.mb.ca