JOURNAL OF MEDICAL & CLINICAL CASE REPORTS

Red arrow: Show the direction of the unexpected table tilt.  Yellow arrow: Point to the head section of the table. Blue arrow: Point to the foot section. Orange arrow: Shows the patient hemodynamically stable after the incident, it's positioned on an auxiliary stretcher, allowing safe airway management and preparation for transfer to another operating room.

Throughout the incident, the patient remained hemodynamically stable, with heart rate maintained between 78/84 beats per minute, blood pressure ranging from 128/76 mmHg to 134/80 mmHg, oxygen saturation consistently at 99/100%, and respiratory rate between 14/16 breaths per minute. Due to the malfunction of the autonomous surgical table, the patient was carefully transferred to the floor in a controlled manner to allow safe induction and endotracheal intubation. Once secured, the patient was transported to another operating room, using an emergency stretcher. Despite the initial disruption, the scheduled surgical procedures proceeded without further complications.

 Meanwhile, the malfunctioning surgical table continued to exhibit autonomous movement for approximately 30 minutes (see Figure 3). The biomedical engineering team responded promptly, conducted an inspection, and ultimately deactivated the table.

Figure 3: Surgical table in continuous movement, acquiring an elevated position. Red arrow: Show the direction of the unexpected table tilt.  Yellow arrow: Point to the head section of the table. Blue arrow: Point to the foot section.

Upon thorough investigation, the engineering team identified a defect in the sealed integrated circuit unit as the cause of the table's malfunction (see Figure 4).

Maintaining patient safety in the perioperative environment is a critical priority for healthcare providers. Identifying and addressing latent risk factors, such as the human element and organizational dynamics, is essential for reducing the likelihood of adverse events and ensuring high-quality care [5]

The prevalence of obesity has become a significant concern in the healthcare industry, particularly in the context of surgical procedures. As the number of obese patients continues to grow, healthcare providers, including anesthesiologists, surgeons, and perioperative nurses, must be well-equipped to manage the unique challenges and risks associated with this patient population.[1]

The importance of following established protocols cannot be overstated. This includes rigorous adherence to guidelines concerning the design, operation, and maintenance of medical devices. Substandard manufacturing practices or inadequate maintenance can lead to device failures, which can have serious implications for patient safety. Therefore, ongoing evaluation and improvement of device management practices are crucial to prevent incidents and safeguard patient well-being.[6]

Automation has been integrated into surgical equipment for decades, with most systems designed for specific, pre-programmed functions. Recent advancements have introduced greater levels of autonomy, enabling operating tables and other devices to perform complex, multi-axis movements without direct manual control. While these innovations can enhance efficiency and precision, they also introduce the possibility of unpredictable mechanical or control-system failures. This underscores the importance of rigorous preoperative equipment testing, established manual-override procedures, and trained staff prepared to respond to unexpected malfunctions during patient care. [7,8]

As surgical equipment incorporates increasingly advanced automation, new technical challenges and safety considerations arise. While these systems can improve efficiency and support precise patient positioning, their complexity also increases the risk of malfunction. This highlights the need for ongoing evaluation of equipment performance, strict adherence to safety protocols, and the implementation of preventive maintenance programs to ensure patient safety.[9]

The proliferation of advanced technologies in healthcare presents both opportunities and risks. Medical professionals must be equipped to manage these risks effectively, especially as the integration of autonomous systems becomes more prevalent. Ensuring comprehensive risk management strategies and adapting safety protocols will be crucial in navigating the evolving landscape of medical technology and maintaining patient safety.[10]

Conclusion

The role of external technological devices in patient safety is often underestimated, yet their failures can have serious consequences. The incident involving the malfunction of an electronic surgical table highlights the potential dangers inherent in relying on such devices. If a relatively simple technological failure can pose significant risks, the implications of a malfunction in truly autonomous systems could be even more severe.

The increasing sophistication of automated surgical equipment presents both benefits and risks in the operating room. This case of a malfunctioning autonomous surgical table during anesthesia induction underscores the importance of heightened vigilance, rapid team response, and established emergency protocols to manage unexpected equipment failures. It serves as a reminder that technological advancement must be matched by robust safety measures and staff preparedness to protect patient welfare.

Disclosures

Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. NO APPLY issued approval NO APPLY. This study did not involve human participants, identifiable data, or patient interventions. It describes the technical setup and functioning of an anesthesia workstation (‘mesa de anestesia’), and as such, no human subjects research was conducted. The institutional ethics committee reviewed the protocol and determined that ethical approval was not required under applicable regulations. No IRB approval number was issued. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.