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Published on: February 16, 2011
Disease model: a simplified approach for analysis and management of human error: a quality improvement study
1From the Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt.
Abstract:
During 6 weeks, we had 4 incidents of echocardiography machine malfunction. There were 3 in the operating room, which were damaged due to intravenous (IV) fluid spillage over the keyboard of the machine leading to burning of the keyboard electric connection, and 1 in the cardiology department, which was damagaed due to spillage of coffee on it. The malfunction had an economic impact on the hospital (about $ 20,000) in addition to the nonavailability of the ultrasound (US) machine for the cardiac patient after the incident till the end of the case and for consequent cases till the fixation of the machine. We undertook an analysis of the incidents using simplified approach. The first incident happened when changing an empty IV fluid bag for a full one led to spillage of some fluid onto the keyboard. The second incidence was due to the use of needle to depressurize a medication bottle for continuous IV drip, and the third event was due to disconnection of the IV set from the bottle during transfer of the patient from operation room to intensive care unit. The fundamental problem is of course that fluid is harmful to the US machine. In addition, the machines are in a position between the patient bed and anesthesia machine. This means that IV pulls are on each side of the patient bed, which makes the machine vulnerable to fluid spillage. We considered a machine modification, to create a protective cover, but this was hindered by complexity of keyboard of the US machine, technical and financial challenges, and the time it would take to achieve. Second, we considered the creation of a protocol, with putting the machine in a position where no IV pulls are around and transferring the machine out of the room when transferring the patient will endanger the machine by the IV fluid. Third, changing of human behavior; to do this, we announced the protocol in our anesthesia conference to make it known to each and every one. We taught residents, fellows, and staff about the new protocol.Our simplified approach was effective for the prevention of fluid spillage over the US machine.
Insights
Echocardiography machine malfunctions caused by fluid spills led to significant costs and downtime. Implementing a new protocol and staff training effectively prevented further fluid damage to ultrasound machines.
Area of Science:
- Medical Imaging Technology
- Biomedical Engineering
- Clinical Operations
Background:
- Echocardiography machines are susceptible to damage from fluid spills, particularly intravenous (IV) fluids and coffee.
- Malfunctions resulted in approximately $20,000 in economic impact and significant machine unavailability.
- Incidents included IV fluid spillage on keyboards and coffee spills, leading to electrical connection damage.
Purpose of the Study:
- To analyze the causes of echocardiography machine malfunctions due to fluid spillage.
- To develop and implement an effective strategy to prevent future incidents.
- To mitigate economic losses and ensure machine availability for patient care.
Main Methods:
- Analysis of four recent incidents involving echocardiography machine damage.
- Evaluation of potential solutions including machine modification and protocol development.
- Implementation of a new protocol and comprehensive staff training on fluid prevention measures.
Main Results:
- The implemented simplified approach, focusing on protocol adherence and human behavior change, was effective in preventing fluid spillage.
- Staff training and protocol announcement at anesthesia conferences raised awareness among residents, fellows, and staff.
- The study demonstrated a successful method for protecting valuable medical equipment.
Conclusions:
- A simplified protocol and targeted staff education can effectively prevent fluid-related damage to echocardiography machines.
- Preventive measures are crucial for maintaining the operational status of critical medical equipment.
- Reducing equipment downtime and associated costs enhances patient care and hospital efficiency.
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