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Using "No Problem Found" in Infusion Pump Programming as a Springboard for Learning About Human Factors Engineering

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Background: A hospital took a second look at a device error with a syringe pump in which a dose of fentanyl was delivered in half the anticipated time. When the nursing staff could not reproduce the error, the pump was sent to biomedical engineering where "no problem was found." The biomedical staff subsequently performed another analysis, which led to discovery of the possible cause of the problem.

Mobilizing for HFE: A human factors engineering (HFE) task force, in considering the fentanyl delivery issue, identified a need to educate nursing and engineering on such incidents and to consider the consequences of override features. The HFE task force then reviewed a tool kit for briefing clinical units on education of staff on clinical safety issues.

HFE Analysis: Efforts to maximize device customization or simplification can have negative HFE consequences. The decision to allow for function overrides or nontraditional equipment use must be weighed against the potential compromises in patient safety.

Summary: The problems that arise from the interface between humans and devices are not limited to intravenous pumps or even medical devices. Awareness of the potential for HFE design flaws can be critical in reducing harm in health care.

Document Type: Research Article

Publication date: September 1, 2004

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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