Cause of Device-Related Incident
User errors

Clinical Specialty or Hospital Department
Anesthesia; Cardiology / Cardiac Catheterization; CCU / ICU / NICU; Clinical/Biomedical Engineering; Dialysis; Emergency Medicine; Nursery; Obstetrics and Gynecology; OR / Surgery

Device Factors
*Not stated

Document Type
User Experience Network (UEN) reports

External Factors
*Not stated

Mechanism of Injury or Death
Failure to deliver therapy; Monitoring failure

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
Accidental spill

UMDNS
Intravenous Poles [12-177]

Electronic Equipment Mounted on IV Poles



User Experience Network™ [Health Devices Apr 1993;22(4):207]

Hospital

We have experienced several incidents in which electronic medical equipment mounted beneath an IV container on an IV pole sustained damage from a fluid spill. In most of the incidents, physiologic patient monitors or their associated accessories and modules short-circuited after fluid from the IV container seeped between two electrically conductive components. A short circuit in a line-powered device could cause tripping of a circuit breaker, with resultant loss of power to devices connected at several receptacles. How can we protect our electronic equipment from such fluid spills?

ECRI

The rolling IV pole is a readily accessible mobile stand for any device that has a pole clamp. As devices get smaller and hospitals place a greater emphasis on mobility, the number of medical devices that can be attached to IV poles will continue to increase. However, electronic equipment (e.g., patient monitors) is especially vulnerable to fluid damage, and such devices should not be mounted below fluid containers unless that is their intended purpose (e.g., IV infusion pumps, enteral feeding pumps).

The lack of guidance on placing electronic equipment on IV poles has concerned several hospitals. Some hospitals have suggested that manufacturers label their units to warn users against hanging IV solutions above them; one hospital even suggested that the manufacturer supply a shield that can be placed above the unit to protect it from fluid spills.

When an electronic device must be easy to move (e.g., from room to room), it is best to mount it on a rolling pole that does not have hooks for suspending any type of fluid container. When mounting the device on a pole with a fluid container cannot be avoided, the device should be shielded in some way to protect it from fluid spills. This need should be discussed with the manufacturer, who may be able to supply a means of fluid protection. Protective shields may be a good idea for manufacturers to consider when designing their units, as well as for hospitals to specify when purchasing new equipment.

UMDNS Term

Intravenous Poles [12-177]

Cause of Device-Related Incident

User error: Accidental spill

Mechanism of Injury or Death

Failure to deliver therapy; Monitoring failure


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