- 期刊
Learning from Patient Safety Incident Investigations: A Case Study
並列摘要
Incident investigations can bring about positive learning experiences by taking the investigation past the point of cause for failure that can influence systemic change. Clinical engineers are well positioned to lead learning opportunities from incident investigations involving medical equipment by encouraging discussion, publication, and collaboration within the medical community. The case presented herein describes a safety event involving a 3100B high-frequency oscillator that failed during patient care, summarizes clinical engineering (CE) findings, and discusses learning opportunities from the adverse event. A physical inspection and disassembly of the failed driver provided visual evidence of heavy wear on the piston in the driver mechanism, and a 180° on the external side, and cracked rubber on the internal side of the diaphragm. These observations were shared with CE departments in the region and three additional ventilators were discovered to have diaphragm safety concerns. Reporting with ECRI Institute and through Health Canada's Canadian Medical Device Sentinel Network (CMDSNet) helped disseminate findings to a broader audience. Following the investigation, respiratory therapy practice was amended and Carefusion revised the wording in their Operator's Manual.