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Device Problems
Image Reversal (1358); Malposition of Device (2616)
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Patient Problem
No Known Impact Or Consequence To Patient (2692)
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Event Date 12/18/2017 |
Event Type
malfunction
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Event Description
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Chest x-ray was done with baby head down in a giraffe bed due to positioning for the endotracheal tube connected to oscillator at the foot of the bed and the baby could not be repositioned.Technologist rotated the image up/down on the machine for the doctor to be able to view the image in a head-up position on the portable screen.Tech verbalized that she was unsure but thought the laterality might be flipped due to the up/down flip.Because of a large tension pneumothorax, anatomic markers were not clear.Technologist left the nicu to return to imaging and annotate laterality with the assistance of her team lead.Meanwhile, the baby continues to decline and a code is initiated.The doctor determined a chest tube was needed emergently.Within a few minutes of the x-ray being taken, before the official radiology read, the nicu physician places a chest tube based on the image he viewed on the portable monitor.Routine confirmation x-ray of the chest tube shows it was placed on the opposite side than intended.A second chest tube is placed to address the original pneumothorax.Follow up simulation of the event determined a very complex software interface made it challenging for technologists to quickly select image adjustment options and clearly understand how the selection might impact the image in multiple directions.Human factors engineer completed usability study of the (b)(6) software involved in the event.
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Event Description
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Chest x-ray was done with baby head down in a giraffe bed due to positioning for the endotracheal tube connected to oscillator at the foot of the bed and the baby could not be repositioned.Technologist rotated the image up/down on the machine for the doctor to be able to view the image in a head-up position on the portable screen.Tech verbalized that she was unsure but thought the laterality might be flipped due to the up/down flip.Because of a large tension pneumothorax, anatomic markers were not clear.Technologist left the nicu to return to imaging and annotate laterality with the assistance of her team lead.Meanwhile, the baby continues to decline and a code is initiated.The doctor determined a chest tube was needed emergently.Within a few minutes of the x-ray being taken, before the official radiology read, the nicu physician places a chest tube based on the image he viewed on the portable monitor.Routine confirmation x-ray of the chest tube shows it was placed on the opposite side than intended.A second chest tube is placed to address the original pneumothorax.Follow up simulation of the event determined a very complex software interface made it challenging for technologists to quickly select image adjustment options and clearly understand how the selection might impact the image in multiple directions.
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Search Alerts/Recalls
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