Disease Model: a Simplified Approach for Analysis and Management of Human Error

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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.

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