2024 FSA Podium and Poster Abstracts

P095: INTRAOPERATIVE FALL FROM THE OR TABLE UNDER GENERAL ANESTHESIA
Giedre Laurinaitis, MD; Nathalie Abitbol, MD, MBA; University of Miami/ Jackson Memorial

Introduction/Background: Falls are frequently reported safety incidents in hospitals but are rather rare events in the operating room. All healthcare team members in the operating room, including anesthesiologists share the common responsibility for managing and preserving patient safety to avoid falls, which may result in increased morbidity and mortality.  

Methods: We describe the case of 61-year-old female, BMI 38.4, with past medical history significant for multiple hip arthroplasties/fractures, who fell off the operating room (OR) Hana table to the floor after having undergone a closed hip reduction. At the end of the procedure, while still intubated and under general anesthesia with a MAC of 2.1, the patient slid off the OR table and ended up in a sitting position on the floor, with the endotracheal tube (ETT) still in place. The fall happened while the anesthesia provider had been left alone in the OR.  

Results: All standard ASA monitors were reattached, and ETT was confirmed to still be in place. Patient was easily ventilated and remained hemodynamically stable. Though she did not have any apparent injury, the surgeon and anesthesiologist discussed best ways to proceed. Given that her head hadn’t hit the floor, it was decided to lay the patient back on a backboard, apply a neck collar and lift her back to her bed for wake up and extubation, prior to sending her for imaging including CT head/neck and hip Xray. Patient woke up uneventfully. She was followed up on post operative day 1, doing well with all imagining results negative. Review of the chart revealed the patient was still under full anesthesia, paralyzed (not reversed yet) making patient movement unlikely to be the reason for the fall. Reviews of OR cameras revealed that the safety perineal post of the Hana table had been removed by the circulating nurse so as to place the wedge at the end of the procedure; this safety post wasn’t reinserted, leading to the patient sliding off the table. 

Discussion/Conclusion: This is a rare case of a fall under general anesthesia from the operating room table. Though this patient was not injured, literature review reveals that other falls in the OR have resulted in morbidity and mortality. Multiple causes can lead to falls from the OR table: patient body habitus, light anesthesia, OR tables not locked, patient safety straps not strapped in place, lack of familiarity of the personal with OR table functioning, and absence/lack of support personnel. All operating room team members need to be vigilant to prevent these events and anesthesia providers should never be left alone to ensure patient safety. 

Hana table with safety strap and blue perineal safety post.