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).

Click to Zoom