By Beverly Albrecht Gallauresi, RN, BS, MPH
(Originally Published February 2004)
During a routine device check in a hospital, a nurse discovered that an external defibrillator battery charger and a suction unit weren't receiving power, even though both appeared to be plugged into the wall outlet. The defibrillator battery wasn't being charged, and the suction unit wasn't ready for use if needed.
What went wrong?
Both devices in this case had similar power cord connectors that appeared to be interchangeable, but the nurse found that each was attached to the wrong device. Although the connectors looked alike, they didn't fit exactly into each other's receptacles. Because of the inexact fit, neither device was receiving power.
Many electronic devices have similar connection ports that can be mistakenly connected to other devices. Fortunately, the nurse discovered this connection error before either device was needed for patient care.
Tips for preventing misconnections
- When using more than one medical device at a time, carefully observe all connections and outlets.
- Read and follow the device manufacturer's labeling for proper device use.
- When charging defibrillator batteries, check to see if the "charging" indicator light is on.
- Notify your facility's biomedical and risk management departments of any dangerous or potentially dangerous issues involving medical devices in your unit.
- Report any patient injury or death that you suspect has been caused by a device misconnection or any device failure.
Although you need to support the adverse event-reporting policy of your health care facility, you may voluntarily report a medical device that doesn't perform as intended by calling MedWatch at 1-800-FDA-1088 (fax: 1-800-FDA-0178). The opinions and statements in this report are those of the author and may not reflect the views of the Department of Health and Human Services.
Beverly Albrecht Gallauresi is a nurse-consultant for the Center for Devices and Radiological Health at the Food and Drug Administration in Rockville, Md. and coordinates Device Safety.