January 29, 2008 | Mark Paradies

Article About Dropping a Patient During Surgery – Family Sues – Root Cause Analysis Points to Communication

An 86-year-old woman (under anesthesia and not conscious) was dropped from a surgery table when a safety belt was released in preparation for transferring her to a mobile hospital bed. She died as a result of the head injury.

The family is suing. The article about the death said:

“The investigative report said the hospital did its own root cause analysis and determined that the doctors and nurses in the operating room were preoccupied with their own tasks and that the ‘removal of the . . . safety belt from the patient was not verbally communicated.'”

“The hospital has adopted a protocol requiring all nurses and doctors put their hands on the patient before removing the safety belt and making sure that there are people on both sides of the table.”

I know this isn’t a complete Sentinel Event Report, but what do you think of “communication” and a policy of “putting their hands on the patient and having people on both sides of the bed before removing the safety belt” as the Safeguards to prevent future accidents? Are these Safeguards strong enough? Will they be effective?

Leave a comment and let me know what you think…


Here’s what the table looks like (I think):

 Med Orthovisiona

Here’s another example:

 Images Ortho

Or another:

 Images Ortho2Forweb

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