The patient was undergoing cardiac surgery.While coming off bypass the patient went into ventricular fibrillation (v-fib).The internal defibrillator paddles did not work.The activation button on the hand-piece did not work and could not be depressed.There was no clicking of the spring-loaded mechanism under the silicone or rubber(?) activation button on the hand piece.The operating room team was required to get a second set of defibrillator paddles which took approximately two extra minutes.This same event has happened with two other patients in the last month and in all cases the activation button on the hand-pieces was defective.We have found five defective sets and will be providing some to zoll for testing.We are reviewing our inventory for additional defective hand-pieces.Manufacturer response for autoclavable internal handles with integrated paddles, zoll (per site reporter).They will test sets that we provide.
|