CASE STUDY #1

Uncontrolled Movement of an OR Table

In this case, a patient was on an OR table during a surgical procedure. Several minutes into the procedure, the table began to move without being directed by OR personnel. Efforts to stop the movement by using the standard or over-ride controls were unsuccessful. Efforts to remove power from the table were also unsuccessful. Eventually, the head and foot sections folded up to their extreme positions and the table tilted fully to one side (first photo). The patient received severe injuries.

A series of carefully-coordinated inspections of the table were conducted by engineering experts, including Matt Baretich. The proximate cause was found to be damage to the stainless steel shroud around the table’s support column (second photo) and consequent internal damage to the over-ride control switches (third photo). The damaged switches caused the table to move without human direction and did not allow the movement to be stopped by OR personnel. A number of factors made attempts to remove power from the table (which had battery backup power) unsuccessful.

Critical issues: Design of the OR table. User and service manuals. Labeling on the table. Compliance with codes and regulation. Staff training. Third-party maintenance procedures. Manufacturer communications.