Investigation summary: the night shift hospital assistant set up operating room bed 6001-01.Circulating rn completed a morning room check which includes the complete check of the operating room 6001-01 bed.The circulating rn completed the bed check of the 6001-01, including: bed locked, all bed components/pieces locked.The circulating rn did not complete the final bed check of correct orientation of all components/pieces.The circulating rn and scrub rn were unaware of the instability of the 6001-01 bed due to the incorrect orientation and configuration of the bed pieces.This was not a bed malfunction.Cause: the omission of the routine check and double check of the 6001-01 bed orientation and configuration of the bed pieces by the hospital assistant and the circulating rn.Actions: educate/re-educate staff (hospital assistants and nurses) on the best practice for routine checks of all operating room beds prior to the start of all surgical procedure.
|