Jove
Visualize
Contact Us
JoVE
x logofacebook logolinkedin logoyoutube logo
ABOUT JoVE
OverviewLeadershipBlogJoVE Help Center
AUTHORS
Publishing ProcessEditorial BoardScope & PoliciesPeer ReviewFAQSubmit
LIBRARIANS
TestimonialsSubscriptionsAccessResourcesLibrary Advisory BoardFAQ
RESEARCH
JoVE JournalMethods CollectionsJoVE Encyclopedia of ExperimentsArchive
EDUCATION
JoVE CoreJoVE BusinessJoVE Science EducationJoVE Lab ManualFaculty Resource CenterFaculty Site
Terms & Conditions of Use
Privacy Policy
Policies

Related Experiment Videos

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
PubMed
Summary
This summary is machine-generated.

Related Concept Videos

You might also read

Related Articles

Articles linked to this work by shared authors, journal, and citation graph.

Sort by
Same author

Ultrasound-Guided Platelet-Rich Plasma Injection for a Medial Collateral Ligament Partial Tear of the First Metatarsophalangeal Joint.

Foot & ankle specialist·2025
Same author

The effect of device geometry on the performance of a wave energy converter.

Communications engineering·2025
Same author

Impact of in-Station Medication Automated Dispensing Systems on Prehospital Pain Medication Administration.

Prehospital emergency care·2022
Same author

Reliability of multi-purpose offshore-facilities: Present status and future direction in Australia.

Process safety and environmental protection : transactions of the Institution of Chemical Engineers, Part B·2020
Same author

Stability of subsea pipelines during large storms.

Philosophical transactions. Series A, Mathematical, physical, and engineering sciences·2014
Same author

Logging on: what it takes to provide patients with computer access.

Biomedical instrumentation & technology·2008

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.

Related Experiment Videos

  • 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.