Causes of use errors in ventilation devices - Systematic review.

Area of Science:

• Biomedical Engineering
• Human Factors Engineering
• Medical Device Safety

Background:

• Mechanical ventilators are critical in patient care.
• Use errors in medical devices can lead to adverse events.
• Variability in ventilator interfaces poses a risk.

Purpose of the Study:

• To identify and categorize the causes of use errors in mechanical ventilators.
• To provide actionable recommendations for manufacturers and standardization bodies.

Main Methods:

• Systematic literature review following PRISMA standards.
• Analysis of 16 papers identified via PubMed search.
• Categorization of error causes using an adapted cause-and-effect diagram.

Main Results:

• Use errors are primarily caused by device-specific usability issues.
• Inconsistent naming of ventilation modes across different devices is a significant factor.
• Medical staff's frequent use of multiple, varied ventilator models contributes to errors.

Conclusions:

• Addressing usability and standardizing interfaces are crucial for reducing mechanical ventilator use errors.
• Design recommendations for manufacturers and adherence to standards like ISO 19223 can improve device safety.
• Mitigating use errors enhances patient safety and optimizes mechanical ventilation therapy.