Beyond Backup Systems: Team-Based Crisis Management During a Pediatric Operating Room Power Failure

Abstract

Objective: Operating rooms are high-risk clinical environments that require an uninterrupted energy supply to ensure patient safety. Although power outages are rare, they can rapidly lead to life-threatening situations, particularly in pediatric patients under anesthesia. Case Presentation: In a pediatric hospital, three operating rooms were actively in use during the morning hours when an unexpected power outage occurred. Although the main power supply was restored shortly thereafter, a technical failure in the generator system resulted in a complete loss of electrical power lasting approximately 12–13 minutes. During this period, anesthesia machines and monitoring systems became nonfunctional. Under the leadership of the anesthesia team, prompt crisis management was implemented; manual ventilation was maintained, surgical procedures were safely suspended, and patients were transferred out of the operating room in a controlled manner. Conclusion: This case demonstrates that technical backup systems alone may be insufficient to ensure patient safety. In unexpected operating room emergencies, team-based crisis management, effective leadership, and clear communication play a critical role in maintaining patient safety.

Keywords

• Operating Room Emergencies
• Power Outage
• Patient Safety
• Crisis Management
• Team-Based Intervention

Yedek Sistemlerin Ötesinde: Çocuk Ameliyathanesinde Elektrik Kesintisi Sırasında Ekip Temelli Kriz Yönetimi

Abstract

Amaç: Ameliyathaneler, hasta güvenliği açısından kesintisiz enerji kaynağına mutlak gereksinim duyulan yüksek riskli alanlardır. Elektrik kesintileri nadir görülmekle birlikte, özellikle anestezi altındaki pediatrik hastalarda hızla yaşamı tehdit eden durumlara yol açabilmektedir. Olgu Sunumu: Bir çocuk hastanesinde sabah saatlerinde üç ameliyathane salonu aktif olarak kullanılmaktayken beklenmeyen bir elektrik kesintisi meydana gelmiştir. Normal elektrik kısa sürede geri gelmesine rağmen, jeneratör sistemindeki teknik arıza nedeniyle yaklaşık 12–13 dakika boyunca tam enerji kaybı yaşanmıştır. Bu süreçte anestezi cihazları ve monitörizasyon sistemleri devre dışı kalmıştır. Anestezi ekibi liderliğinde hızlı bir kriz yönetimi uygulanmış; manuel ventilasyon sağlanmış, cerrahi işlemler güvenli şekilde durdurulmuş ve hastalar kontrollü biçimde ameliyathaneden transfer edilmiştir. Sonuç: Bu olgu, teknik yedek sistemlerin tek başına yeterli olmadığını; ameliyathane acil durumlarında ekip temelli kriz yönetimi, liderlik ve etkili iletişimin hasta güvenliği açısından kritik olduğunu göstermektedir.

Keywords

• Ameliyathane Acilleri
• Elektrik Kesintisi
• Hasta Güvenliği
• Kriz Yönetimi
• Ekip Temelli Müdahale

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