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Using "no problem found" in infusion pump programing as a springboard for learnning about human factors engineering
Scott Draper1, Gail A Nielsen, Mike Noland
1Bio-tech Services Department, Iowa Health System, Des Moines, USA.
Joint Commission Journal on Quality and Safety
|October 8, 2004
Summary
A syringe pump error delivering fentanyl too quickly was investigated. Human factors engineering (HFE) analysis revealed that device customization and overrides can compromise patient safety.
Area of Science:
- Medical Device Safety
- Human Factors Engineering
- Clinical Engineering
Background:
- A hospital investigated a syringe pump malfunction where fentanyl was delivered at twice the intended rate.
- Initial investigations by nursing staff and biomedical engineering did not identify the error.
- Further analysis by biomedical engineering uncovered the potential cause of the malfunction.
Purpose of the Study:
- To educate nursing and engineering staff on device-related incidents.
- To assess the patient safety implications of device override features.
- To review educational tools for clinical safety issue briefings.
Main Methods:
- A human factors engineering (HFE) task force was convened to analyze the incident.
- The task force reviewed the fentanyl delivery error and considered the role of device overrides.
- A toolkit for educating clinical units on safety issues was examined.
Main Results:
- Maximizing device customization or simplification can lead to negative HFE consequences.
- Allowing function overrides or non-traditional equipment use requires careful consideration of patient safety risks.
- The interface between humans and medical devices presents potential HFE design flaws.
Conclusions:
- Awareness of HFE design flaws is crucial for reducing harm in healthcare.
- Problems related to human-device interaction extend beyond intravenous pumps and medical devices.
- Balancing device functionality with patient safety is paramount.