Use Your Technical Expertise to Improve Use Errors

by Julie Kirst 9/15/2010 8:30:00 AM

For this post we welcome guest blogger, Ruperto A. Glaize, A CIV US USA MEDCOM, equipment maintenance, Womack Army Medical Center, who shares his best practices concerning use errors, based on his observations from working in small rural hospitals the past few years. Here’s what he says:

“As more and more of the equipment is computer based, your work force is less and less capable of using it. They want to turn it on, push one or two buttons, and that’s it. If someone accidentally changes one setting, most nurses are incapable of resetting the unit back to their perceived “natural” setting.

In the higher skilled areas (ICU, NICU, etc) the common use errors occur during crisis moments when the nurses are totally focused on patient care and are unable to step back for a second, process what the unit is doing or not doing. They would rather shut the unit down, disconnect the patient, bring in another unit, then reconnect the patient.”

Rupert has found that on the wards/floors, most nurses are CNAs who, unfortunately, are not very adept in using most equipment. He has noted that “if the equipment alarms for any reason, they will just put it to the side with a ‘broken’ sign on it.”

His solution? “I understand that with budget concerns education is usually one of those areas that will be easy for the hospital to cut. As biomeds we are the technical experts for the hospital and we must work very close with the education department to make sure that the hospital work force is a competent work force. Having the latest, greatest, state of the art equipment does us no good if the work force does not know or understand how to properly use the equipment.”

Our thanks to Rupert and we hope you'll comment on his blog and share your own best practices.


 

 

 

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Comments

Posted by vsarmiento, 9/17/2010 6:58:29 AM

I agree with Mr. Rupert Glaize findings and how to minimize user related problems. It is a training issue that should be immediately addressed or implemented. Spearheaded by the nursing education people in coordination with the biomedical engineering group.   They should also start a train the trainer program for a continued on the floor training or hand-holding by a supervisory nurse who are considered as the super user for a given nursing application.

Posted by Andy Veeriah, 9/22/2010 11:10:30 AM

User training(or lack of it)is one of the reasons for improper use of equipment and the resultant errors. It is crucial to training all the users and more importantly to document the competency of the individual users(This is a requirement from JC and DNV) I am not sure whether biomed staffs are qualified to educate the clinical users however, I do believe that biomeds play an important role in coaching the users to use the manufacturer instructions and manuas to understand and manage the alarm conditions. Some of the hospitals and medical centers I have worked in the past had dedicated clinical training staff/dept biomed staff need to work this designated staff and manufacturers in development and implementation of the training program.

Posted by George Koning, 10/13/2010 5:15:39 PM

The first step to ensuring clinicians step up to the plate to understand the devices they use is to make the user information is universally accessible throughout the hospital 24/7 – those technically competent and inquisitive clinicians then become the product champions and reference point for other staff etc etc

I have achieved this by building the following system:

www.bioclinicalservices.com

The biomedical department is the pivotal point in the medical device internal distribution chain and hence ideally suited to ensure all users have access to this information

Enthusiasm , encouragement , support , engaging them – these are better , cheaper tools which ensure safer hospitals


Posted by jim, 11/15/2010 5:13:08 PM

I agree with Mr. Rupert Glaize findings and how to minimize user related problems. It is a training issue that should be immediately addressed or implemented. Spearheaded by the nursing education people in coordination with the biomedical engineering group.   They should also start a train the trainer program for a continued on the floor training or hand-holding by a supervisory nurse who are considered as the super user for a given nursing application.

Posted by Russ Allen, 11/25/2010 12:33:23 PM

I agree with Mr. Glaize. I am soon to be biomed after internship from SCC in West Burlington, Iowa. I will take this one step further if I may from a person coming from a factory computerized machine. I realize a factory situation is different than in a life situation, but my experience on running lasers at John Deere Ottumwa Works and any computer related equipment, especially in medical field needs proper training. Fall too often I see people who are not trained push a button or two on my machines not trained or what are told to my management to do so without thinking about consequences. I realize this may may be a poor analogy, but computers are "human" too! We have to be properly trained, not on operation but troubleshooting, not just putting a note on machine and saying it doesnt work. Again I am not in this field yet, but will keep open mind on the delicate nature of current and in the future medical equipment. Thanks for listening. Russ Allen Mt. Pleasant,Iowa

Posted by Roseanne Kirchherr, 6/23/2011 6:16:07 AM

This is definitely a great post .

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