Patient safety incidents associated with equipment in critical care: a review of reports to the UK National Patient Safety Agency

Abstract

SummaryWe reviewed all patient safety incidents reported to the UK National Patient Safety Agency between August 2006 and February 2007 from intensive care or high dependency units. Incidents involving equipment were then categorised. A total of 12 084 incidents were submitted from 151 organisations (median (range) 40 (1-634) per organisation). Of these, 1021 incidents were associated with use of equipment, most commonly involving syringe pumps ⁄ infusion devices (185 incidents), ventilators (164 incidents), haemofilters (107 incidents) and monitoring equipment (70 incidents). Twenty-nine incidents were associated with more than temporary harm to patients. Failure or faulty equipment was described in 537 incidents (26% with some harm) and incorrect setting or use was described in 358 incidents; these were more likely to be associated with harm (39%; p = 0.001). We suggest changes to improve the reporting of incidents and to improve equipment safety.

Slips, lapses and mistakes inthe use of equipment by nurses in an intensive care unit

“…One of the areas of interest of the program is safe use of equipment, given the variety of devices, manufacturers, technical specifications to operate each equipment, and the need for knowledge and attention to manage these aspects (1) . This concern is based on evidence from the literature on the occurrence of user errors in the handling of equipment, especially in the intensive care unit (ICU) environment (2)(3)(4)(5) , which has a large presence of such equipment. Equipmentrelated incidents, known as adverse events (1) , have caused harm to patients, as shown in studies on this subject.…”

“…In that study, 358 of 1,021 adverse events analyzed were due to incorrect use of equipment, making it the most frequent cause of harm to patients. The authors noted that of the 1,021 adverse events studied, 29 were associated with more than temporary damage, which resulted in longer stay in the ICU, permanent damage and interventions to maintain life and even possible reasons for death (3) . Findings from a third study that measured the stimulusresponse time of the health team to alarms from monitoring equipment in intensive care corroborated the foregoing studies.…”

Tecnologias na terapia intensiva: causas dos eventos adversos e implicações para a Enfermagem

“…In this study, manufacturing errors were associated with the physical design and spacing of buttons; the size, format, and grouping of buttons; to which extent the device design is intuitive; reversion to the standard mode with no previous warning; overcrowding of the graphic interface; and degree of transparency of operations, among others (12) . In the surveys selected for this study, defects and malfunctioning of equipment were associated with damages to patients, including those classified as longer than temporary (22) . This fact has raised questions about the evaluation of effects ensuing from technologies.…”

“…Failure in checking the equipment can lead to some aspects of team failure, such as excessively relying on technologies, and poor communication between members to plan means to grant more autonomy to batteries, notably during the transfer of patients. Data show that communication problems interfere with the proper working of devices, such as lack of previous communication about the power generator test times to enable the due care to prevent further malfunctioning of the device (22) . There are similarities between this result from team failure related to equipment use and other safety spheres in intensive care.…”

Review on Design for Medical Device

“…Reported by the European Pressure Sore Advisory Panel grades that 119 cases of pressure sore are associated with medical device. In 87 cases of pressure sore which are often associated with medical device are being presented on admission, suggested that implementation of care and regular monitoring should be implemented [9][10] [11]. There is no 'accurate' or 'safe' number of patient safety to be considered as safe however a 'low' reporting rate can be interpreted as 'safe' and a 'high' report rate can be describe as 'unsafe' which represent culture of greater openness [12].…”