A (b)(6) patient ordered to receive e-stim therapy s/p shoulder impingement syndrome.During a second round of e-stim therapy, the medical device stopped working (setting of 20pps).Upon restarting the device, the setting button jumped from 15pps to 50pps causing pain to the patient's shoulder.The device was turned off and a red mark was noted on the shoulder.No skin blistering noted, soft tissue massage and ice application to affected area provided relief.No adverse effect was ever reported and the patient subsequently returned for additional therapy.Complete inspection of device was done by the facility bio-med department and they reportedly were unable to replicate the event.It was then sent to the manufacturer and they reportedly were unable to replicate the event but replaced the keypad.
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