Minnesota Hospital Association

Quality & Patient Safety

May 02, 2007

Minnesota Patient Safety Alert: Potential for Retained Laparoscopic Argon Beam Coagulator Tip

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.