A recent headline in a newspaper caught my attention. The headline read: “Man falls off surgical table; St. Joseph's Hospital Sued”. The article appeared in the Star Tribune, a newspaper in Minneapolis, MN. The article stated that a man was sedated for a routine surgery when he rolled off the operating table and hit his head. The man later died and the family is suing the hospital because they feel the hospital didn’t use proper procedures and equipment to ensure his safety. In the article the man was described as 5’5” and weighed about 300 lbs. It stated that this was the fourth surgery to replace a drain the man had since suffering a stroke. The family’s attorney was quoted as saying the table’s three Velcro straps couldn’t hold him. The lawsuit contends that the hospital lacked “appropriate facilities and equipment, including wide enough tables and adequate restraints to perform an operation…” The suit argues that his weight “is not unusual or abnormal weight...”
This story is both tragic and sad. It clearly shows the importance of safe patient handling (SPH). It also is a lesson that those of us involved in SPH can and should learn from. We need to ask ourselves “What went wrong?” and “What can we do to prevent it from happening again?” The only information available is what was included in the article. Based upon that article there are questions that come to mind about what errors took place, and/or what system and/or processes were in place to prevent such an incident from occurring. We need to consider the patient’s size, a typical operating table, patient restraint straps, the policies/procedures for securing patients to the table, and common safe patient handling practices.
First, let’s consider the patient’s size. According to the article the man weighed approximately 300 lbs. 300 lbs. in and of itself is not an unusual weight. One can also say that a height of 5’5” is not uncommon either. So now we must consider the combination of 5’5” and 300 lbs. According to the U.S. National Institutes of Health, a BMI of 18.5-24.9 is normal weight, 25-29.9 is overweight and > 30 is obese. Some medical organizations such as the Cleveland Clinic classify morbidly obese as a BMI > 35. The Cleveland Clinic BMI calculator shows that a person 5’5” tall is overweight at 150 lbs., is obese at 180 lbs. and is morbidly obese at 210 lbs. Based upon this information it is clear that this patient was morbidly obese. So we are left to ask ourselves if this combination is unusual. Given the USA’s increasing waistlines over the past few decades it appears that this would not necessarily be the case. The current numbers posted by the National Center for Health Statistics show that more than 34 percent of Americans are obese, compared to 32.7 percent who are overweight. It said that just under 6 percent are “extremely” obese. The NCHS report stated that “more than one-third of adults (those over age 20), or over 72 million people, were obese in 2005-2006”. These figures came from the 2005-2006 survey which are the most current available. So one can conclude that this man’s size is not unusual, however it would not be common either. A patient of this size would have a sizeable panus (abdominal region) and therefore his width would be considerably greater than a 5’5” person with a normal weight BMI. The size and width of the patient should to be taken into consideration when choosing the operating table and patient restraint straps.
This leads into the consideration the operating room table itself. A general operating table width is approximately 20”. Some tables have the option to add on extensions that can increase the width to 28”. Weight capacity can vary from 500 lbs. to 1200 lbs. (source www.steris.com). There are also different size patient restraint straps that can be used to secure the patient to the table. Common restraint straps come in 2”, 4” and 6” widths. The length of the strap varies depending on if the strap attaches to the table rail or if it wraps entirely around the table. The type and number of straps used should be based upon the patient size, procedure and table. So for bariatric patients, one can assume that a table with extenders and multiple restraint straps that are wide and extended in length should be used. This would ensure enough strap material in contact with the patient and that there is ample overlap of the Velcro material to hold securely in place. This assumes that the hospital has operating tables that have the capability of adding extensions and a supply of different sized restraint straps.
Safe patient handling and movement has been focused on just that -- handling and movement. It is common practice to address how to move and transfer patients laterally (i.e. on/off a bed, gurney or table), vertically (i.e. bed to chair) and repositioning (i.e. boosting or turning on a bed, gurney or table). It may not always be intuitive to address patients that are stationary. In this incident the patient was safely transferred to the operating table. It is when the patient was on the operating table and not being moved when the incident occurred. Ask yourself this question, “Does your SPH program address patients that need to be stationary? Hospitals usually have a policy in place that requires three out of the four side rails be up when the patient is in bed and that both side rails be in the up position when a patient is in a gurney. This policy is in place to prevent patients from falling off the bed or gurney. But what happens when there are no side rails? How is a patient secured on tables that don’t have side rails, i.e. x-ray, MRI, operating room table, etc.? A fairly standard practice in safe patient handling is to have a flowchart or algorithm of what equipment and accessory item should be used to transfer or move a patient based upon the task and size of the patient. However, it may not be instinctive to have a similar algorithm in place when patients need to be stationary. It is vital for patient safety that the choice of equipment and accessory items matches the patient and the task. This incident shows the importance of having policies and procedures in place specifically for these situations.
Another possibility to what went wrong is simply human error. It is possible that the hospital had policies and procedures in place for these “stationary patient” situations, had a patient algorithm and had the correct operating table and straps available for staff to use. What we know of from this incident is that the first three surgeries went off without an incident so one can assume that the patient was secured appropriately to the table. For some reason that wasn’t the case for the fourth surgery. Were the policies and procedures not followed? Was a different operating table used? Were different size straps or a different number of them used? Or, was this the result of someone not securely fastening the Velcro straps? Unfortunately, we do not have the answers to those questions.
The challenge in safe patient handling will always remain how to eliminate human error in the decision making process. Even after safe patient handling culture is established and all of the processes to support SPH are in place, it still comes down to the decision making process and judgment of the caregivers involved with the patient, to decide what equipment to use and to use it correctly. Unlike a manufacturer that has converted to using robotics to assemble a widget, we can’t engineer out the humans in SPH. There will always be some amount of error. The goal in SPH needs to become how to get that error rate as close to zero as possible.
Jill Kelby is the president of Ergo-PATH System, LLC. She can be reached at firstname.lastname@example.org. Ergo-PATH System, LLC offers SPH training and consulting to healthcare facilities. Only one more SPH System training seminar is left for this year. Visit their website, www.ergo-pathsystem.com, for further information on their services.