Education

Case serial: SCH-2021-04
Title: Intermittent pneumatic compression device system & leg sleeve

Description

Patient Condition

  • A 86-year-old male patient had an orthopedic surgery for femur fracture.
  • The patient tried to apply the intermittent pneumatic compression device system to prevent deep vein thrombosis.

Events

  • The nurse found air leaks at the tubing line (connects leg sleeve and tubing pocket). Refer to Figure (a).

Post-event management & Health effect

  • The patient applied a new leg sleeve.
  • No significant health complications occurred.

Investigations (Cause, Improvements)

  • Interview of patient carer
  • Patients put the leg sleeve on or off repeatedly for their convenience in wards.
  • During that process, the patient pulled off the leg sleeve repeatedly from the tubing pocket, without holding the tubing pocket, which resulted in a tear in the tube which connects the tubing pocket to the leg sleeve.
  • Added a transparent cap on the tubing pocket, which the buttons on each side of the pocket need to be pressed for the leg sleeve to be disconnected.
  • This prevents patients from pulling off the leg sleeve without holding the tubing pocket. Refer to Figure (b).

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Annex

Code

#

%

A A01 - Lower Level Codes 13 28.9%
A A05 - Lower Level Codes 9 20.0%
A A12 - Lower Level Codes 5 11.1%
A A22 - Lower Level Codes 3 6.7%
A A23 - Lower Level Codes 3 6.7%
A A02 , A26 , A14 , A15 , A21 , A25 , A03 , A04 , A11 12
total:45
26.7%
B B13 - Lower Level Codes 13 39.4%
B B01 - Lower Level Codes 8 24.2%
B B15 - Lower Level Codes 2 6.1%
B B18 - Lower Level Codes 2 6.1%
B B03 - Lower Level Codes 2 6.1%
B B06 , B16 , B17 , B19 , B23 6
total:33
18.2%
C C23 - Lower Level Codes 13 41.9%
C C07 - Lower Level Codes 8 25.8%
C C13 - Lower Level Codes 3 9.7%
C C16 - Lower Level Codes 1 3.2%
C C17 - Lower Level Codes 1 3.2%
C C19 , C01 , C04 , C05 , C06 5
total:31
16.1%
D D11 - Lower Level Codes 18 50.0%
D D01 - Lower Level Codes 6 16.7%
D D08 - Lower Level Codes 3 8.3%
D D12 - Lower Level Codes 2 5.6%
D D02 - Lower Level Codes 2 5.6%
D D14 , D16 , D05 , D06 , D07 5
total:36
13.9%
E E24 - Lower Level Codes 17 56.7%
E E21 - Lower Level Codes 3 10.0%
E E05 - Lower Level Codes 3 10.0%
E E16 - Lower Level Codes 2 6.7%
E E22 - Lower Level Codes 1 3.3%
E E01 , E02 , E09 , E20 4
total:30
13.3%
F F26 - Lower Level Codes 15 51.7%
F F05 - Lower Level Codes 5 17.2%
F F27 - Lower Level Codes 2 6.9%
F F10 - Lower Level Codes 2 6.9%
F F01 - Lower Level Codes 1 3.4%
F F08 , F09 , F21 , F24 4
total:29
13.8%
G G04 - Lower Level Codes 22 66.7%
G G06 - Lower Level Codes 5 15.2%
G G01 - Lower Level Codes 3 9.1%
G G03 - Lower Level Codes 1 3.0%
G G05 - Lower Level Codes 1 3.0%
G G07 1
total:33
3.0%

ballon? connector?

Soo Jeong Choi , Republic of Korea
[ 2021-09-04 07:32:25.0]

Component code is not easy for me.

[2]

Patient education

María Eugenia Villalobos-Hernández , (Non-APEC) Costa Rica
[ 2021-09-12 03:28:25.0]

It is very need to educate or train any patient in how to use the device or how to handle, this will contribute to prevent device misuses and therefore protect patient`s health. specially for elderly people or children.

[1]

It was a useful case.

Soohyun Nam , Republic of Korea
[ 2021-09-16 10:17:32.0]

It was a useful case. thank you.

[0]

Intermittent pneumatic compression device system & leg sleeve

Stevie Lee , Republic of Korea
[ 2021-09-16 14:03:05.0]

it was a useful activity

[0]

Incident vs adverse event

María Del Rocío Peinador Roldán , (Non-APEC) Costa Rica
[ 2021-09-16 23:22:21.0]

What's the difference between an incident and an adverse event?

[0]

Incident in intermittent pneumatic compression device system and leg sleeve

Erika Masis , (Non-APEC) Costa Rica
[ 2021-09-20 11:52:05.0]

Because of the lack of education of the patient in its use.

[0]

Incident in intermittent pneumatic compression device system and leg sleeve.

Erika Masis , (Non-APEC) Costa Rica
[ 2021-09-20 11:55:04.0]

Because of the lack of education of the patient in its use.

[0]

Intermittent pneumatic compression device system & leg sleeve

Seontae Kim , Republic of Korea
[ 2021-09-21 18:19:22.0]

Useful cases study

[0]