Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 3 (Sept. 2005) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Patient Receives Shock During Defibrillator Operational Check D efibrillators are routinely checked for proper op- eration by clinical staff typically at the beginning of each nursing shift. The check by the nursing staff is discharge tests, which may also impact the frequency of operational checks. relatively basic compared to the more extensive in- The visual check1 typically consists of the following spection and preventive maintenance of the defibrilla- procedures but may vary among facilities: tor performed by hospital clinical or biomedical engi- neering personnel. The operational check is per- • Ensuring that the defibrillator’s chassis is in- formed to ensure that the defibrillator is performing as tact, clean, free from spills, and void of any intended and properly supplied with the appropriate objects on and around the unit that may inter- accessories (e.g., monitoring electrodes, conductive fere with properly using the device. gel) in the event it is needed during a patient resusci- tation attempt. • Verifying that all appropriate accessories such as monitoring electrodes are present PA-PSRS received a report describing a patient re- and within the expiration date. ceiving an unintentional shock of approximately 150 joules (J) during a daily bedside defibrillator check, • Verifying that paddles are clean and not pit- but was reportedly uninjured during the event. Ac- ted and that they release from the defibrillator cording to the report, a nursing assistant (NA) was chassis easily. doing the check. The NA believed she was checking the defibrillator using the device’s paddles, but didn’t • Inspecting cables and connectors for damage realize that electrodes (pads) were affixed to the pa- and that the connectors are securely at- tient at the time. tached. In some situations, clinicians may use a defibrillator, • Verifying that the AC charger is plugged into with physiologic monitoring capability, to monitor pa- a “live” electrical outlet and that the AC power tient vital signs (ECG, SpO2). This practice is some- and/or battery-charging indicators are illumi- times used when no other monitoring option is avail- nated. able. However, a major disadvantage of this practice is that defibrillators do not allow for central alarm noti- fication. Defibrillators do not incorporate any safety • Verifying that a fully charged battery is in mechanisms to prevent unintentional energy dis- place. charges from occurring. • Verifying that all appropriate indicators and Regardless of whether a defibrillator is used as a displays are functional. physiologic monitor, operational checks should never be performed while the unit’s electrodes are attached • Verifying that the device has sufficient paper to anyone. Consider limiting the performance of op- for ECG recording. erational checks to nurses or to equally qualified clini- cians, rather than a nursing assistant or other non- qualified staff member who may not be intimately knowledgeable of the functions of a defibrillator and This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 2, No. 3—Sept. 2005. The Advisory is a publication of the Pennsylvania Patient the dangers it can present. Safety Authority, produced by ECRI & ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Visual checks are typically performed daily and op- erational checks weekly. However, before revising Copyright 2005 by the Patient Safety Authority. This publication may be re- printed and distributed without restriction, provided it is printed or distributed in any procedures, review the defibrillator manufac- its entirety and without alteration. Individual articles may be reprinted in their turer’s recommended operational check procedure entirety and without alteration provided the source is clearly attributed. and frequency of testing. Also, some current defibrilla- tor models perform automatic weekly or daily self- To see other articles or issues of the Advisory, visit our web site at www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2005 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 3 (Sept. 2005) Patient Receives Shock During Defibrillator Operational Check (Continued) The operational check1 typically consists of the follow- ing procedures but, again, may vary: • Verifying proper operation of the pacemaker feature, if so equipped. • Verifying proper operation by performing en- ergy charge and discharge cycles during bat- tery operation according to the manufac- turer’s recommendations. Suggestions for mitigating shock hazards to patients and staff during defibrillator operational checks in- clude: • Providing education and training on the proper operation, operational check, and dan- gers associated with using or testing defibril- lators. • Allowing only qualified clinical staff to perform defibrillator operational checks. • Consulting the defibrillator’s user manual or contacting the manufacturer for directions on performing operational checks and the fre- quency of checks. • If possible, avoiding use of a defibrillator as a physiologic monitor. If its use as a monitor is unavoidable, discontinue operational checks while the device is in contact with patients. Notes 1. ECRI User Checklist for Defibrillator/Monitor/Pacemakers [Evaluation]. Health Devices 1993;22(5-6):292. Page 2 ©2005 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 3 (Sept. 2005) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. ©2005 Pennsylvania Patient Safety Authority Page 3