Human factors engineering is the discipline that attempts to identify and address these issues. Multiple brands of defibrillators exist that differ in physical appearance as well as functionality a typical hospital may have many different models scattered around the building, sometimes even on the same unit. Full-dose and prophylactic-dose heparin vials appear virtually identical, and both concentrations are routinely stocked in automated dispensers at the point of care. The bag of epidural anesthetic was similar in size and shape to IV medication bags, and, crucially, the same catheter could access both types of bags. Each of these safety hazards ultimately was attributed to a relatively simple, yet overlooked problem with equipment design. But as these examples illustrate, the interaction between workers, the equipment, and their environment can actually increase the risk of disastrous errors.
An elderly man experiences cardiac arrest while hospitalized, but when the code blue team arrives, they are unable to administer a potentially life-saving shock because the defibrillator pads and the defibrillator itself cannot be physically connected.īusy health care workers rely on equipment to carry out life-saving interventions, with the underlying assumption that technology will improve outcomes.
Newborns in a neonatal intensive care unit are given full-dose heparin instead of low-dose flushes, leading to three deaths from intracranial bleeding. An obstetric nurse connects a bag of pain medication intended for an epidural catheter to the mother's intravenous (IV) line, resulting in a fatal cardiac arrest.
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