LEBANON, IN – An internal mass casualty incident was declared at Saint Sebastian Hospital on Thursday morning after an ICU physician inadvertently discharged a defibrillator, resulting in six wounded. A respiratory therapist, two ICU nurses, a resident, a pharmacist, and a medical student were among the casualties, all currently listed in guarded condition.
The physician, Dr. Charles Lu, had been in the middle of multidisciplinary rounds when the accident occurred. Witnesses described a scene of confusion and panic after Dr. Lu approached a defibrillator that had been inadvertently left on from being checked during morning hand off. “It was pandemonium,” reported nurse Tim Khan. “One moment it was quiet, and the next thing you knew there were six people on the floor screaming, swearing, and trying to strangle Dr. Lu.”
A preliminary investigation by the hospital’s health and safety department suggests that the accident was caused by Dr. Lu’s attempt to push the defibrillator charge and shock buttons at the same time in an effort to titrate the unit, while the defibrillator pads were lying on a counter top.
While it is not clear as to why an ICU attending would touch a defibrillator, accident investigators have a main theory. “It is a well known phenomenon that ICU attendings are attracted to anything with flashing lights,” noted Dr. Lena Sykes, the lead investigator. “This trait, coupled with an instinctual behavior to press buttons and turn knobs, has the potential for devastating consequences.”
Despite the large number of casualties, hospital administrators are labeling this accident as a near miss. “Thankfully patient care was not affected by this incident,” noted hospital CEO Dr. Robert Page. “Can you imagine what would have happened if Dr. Lu had tried to use the defibrillator during a code?” Dr. Page pledged to implement interim safeguards, including measures such as posting EM interns in front of ICU defibrillators at all times.
The Joint Commission has since issued an interim safety advisory stating that all ICU electronic equipment not in use should be kept off and out of visual sight of any ICU attending.
