PA PSRS Patient Saf Advis 2005 Sep;2(3):19-20.
Patient Receives Shock During Defibrillator Operational Check
Critical Care; Emergency Medicine; Nursing
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Patient Receives Shock During Defibrillator Operational Check

Defibrillators are routinely checked for proper operation by clinical staff typically at the beginning of each nursing shift. The check by the nursing staff is relatively basic compared to the more extensive inspection and preventive maintenance of the defibrillator performed by hospital clinical or biomedical engineering personnel. The operational check is performed to ensure that the defibrillator is performing as intended and properly supplied with the appropriate accessories (e.g., monitoring electrodes, conductive gel) in the event it is needed during a patient resuscitation attempt.

PA-PSRS received a report describing a patient receiving an unintentional shock of approximately 150 joules (J) during a daily bedside defibrillator check, but was reportedly uninjured during the event. According to the report, a nursing assistant (NA) was doing the check. The NA believed she was checking the defibrillator using the device’s paddles, but didn’t realize that electrodes (pads) were affixed to the patient at the time.

In some situations, clinicians may use a defibrillator, with physiologic monitoring capability, to monitor patient vital signs (ECG, SpO2). This practice is sometimes used when no other monitoring option is available. However, a major disadvantage of this practice is that defibrillators do not allow for central alarm notification. Defibrillators do not incorporate any safety mechanisms to prevent unintentional energy discharges from occurring.

Regardless of whether a defibrillator is used as a physiologic monitor, operational checks should never be performed while the unit’s electrodes are attached to anyone. Consider limiting the performance of operational checks to nurses or to equally qualified clinicians, rather than a nursing assistant or other nonqualified staff member who may not be intimately knowledgeable of the functions of a defibrillator and the dangers it can present.

Visual checks are typically performed daily and operational checks weekly. However, before revising any procedures, review the defibrillator manufacturer’s recommended operational check procedure and frequency of testing. Also, some current defibrillator models perform automatic weekly or daily self-discharge tests, which may also impact the frequency of operational checks.

The visual check1 typically consists of the following procedures but may vary among facilities:

  • Ensuring that the defibrillator’s chassis is intact, clean, free from spills, and void of any objects on and around the unit that may interfere with properly using the device.
  • Verifying that all appropriate accessories such as monitoring electrodes are present and within the expiration date.
  • Verifying that paddles are clean and not pitted and that they release from the defibrillator chassis easily.
  • Inspecting cables and connectors for damage and that the connectors are securely attached.
  • Verifying that the AC charger is plugged into a “live” electrical outlet and that the AC power and/or battery-charging indicators are illuminated.
  • Verifying that a fully charged battery is in place.
  • Verifying that all appropriate indicators and displays are functional.
  • Verifying that the device has sufficient paper for ECG recording.

The operational check1 typically consists of the following procedures but, again, may vary:

  • Verifying proper operation of the pacemaker feature, if so equipped.
  • Verifying proper operation by performing energy charge and discharge cycles during battery operation according to the manufacturer’s recommendations.

Suggestions for mitigating shock hazards to patients and staff during defibrillator operational checks include:

  • Providing education and training on the proper operation, operational check, and dangers associated with using or testing defibrillators.
  • Allowing only qualified clinical staff to perform defibrillator operational checks.
  • Consulting the defibrillator’s user manual or contacting the manufacturer for directions on performing operational checks and the frequency of checks.
  • If possible, avoiding use of a defibrillator as a physiologic monitor. If its use as a monitor is unavoidable, discontinue operational checks while the device is in contact with patients.

Note

  1. ECRI User Checklist for Defibrillator/Monitor/Pacemakers [Evaluation]. Health Devices 1993;22(5-6):292. 
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