Improvised Use of Medical Devices

For various reasons, providers may choose to modify or repurpose a medical device, workflow, or system. However well-intended, such improvisation may lead to serious safety and regulatory compliance issues. Consider, for example, the following event submitted to ECRI and the ISMP PSO:

*A COVID-19 positive patient was placed in a room with the ventilator outside the room to conserve personal protective equipment (PPE). While the nurse was connecting intravenous tubing through a hole in the wall, the heater plug on the ventilator circuit became disconnected. It took several seconds to reconnect the plug, potentially exposing staff to contagions. ...