A report submitted
to the Patient Safety Registry highlighted a potential issue with a change in the protector of a laparoscopic argon beam coagulator manufactured
by CONMED. Previously the protector
for this device was bright
yellow. Recently a change was made to
the instrument — the current models have a smaller black protector, which is the same color as the shaft of the
instrument. The packaging of the new instrument
contains
a warning to “remove the yellow protector before use” and has not been updated
to correspond with the change to the black protector. These factors may increase the chances of the protector not being
removed thus potentially resulting
in a retained foreign object.
The manufacturer has been notified of these
concerns. MHA and MDH would appreciate your help in notifying the appropriate staff within your facilities of this
potential patient safety issue.