Case serial: SCH-2022-01-004
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Title: Intermittent pneumatic compression device system & leg sleeve
- 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.
- 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).
Select the most appropriate IMDRF code for the description.