Hi Dominic ,
Yes I have seen that one – notice how the nursing staff are ignored ( just like in this case
http://www.courts.qld.gov.au/__data/assets/pdf_file/0004/86755/cif-mcvey-os-20081128.pdf - page 10 & 27 ) - and in the case of Clare Bowen – the expert witness had never used that particular device ??? ( for those who haven’t watched it )
As a hospital based biomeds, competent nursing staff are our partners in safe outcomes with respect to equipment 99% of the time – we all know this and many of us treat Nurses with the same arrogance when it comes to User Errors – and at the same time having never to deal with equipment issues under the type of pressure you exposed to in the Bromley video – its easy criticise users when you got a device in your workshop , a cuppa and some Mozart in the background .
A competent nurse can set the tone and manage all the background chaos in theatre when things are not going well and the tend to be first responders to most incidents in hospitals – I setup and demonstrated Phaco machines for Allergan (back then) for 8 years (for those who don’t know – most patients are awake so there are lots of hand signals, glares and short abrupt statements when things go wrong )
So rather than just talk about it - I have done this :
http://bioclinicalservices.com.au/( sorry to harp on this Geoff ) – making sure nurses have access to product specific info 24/7 is , in my opinion , the first step to changing the culture of all staff to medical equipment
Geoff ;
You quite right – if we not doing it , what’s the point – these guys looked a 8 hospitals and + 40 000 devices - User Error ( they spoke about NFF and User induced errors ) was the most common issue with respect all device categories – PM detected very few device errors
Its interesting – the Alaris Asena has a recommended 3 yr pm schedule and most other syringe drivers have a 12 month one – and I don’t really see much different inside each – and that’s the issue when resources are limited .
I think the point is that someone needs to go first with respect to putting their neck out and saying “ we don’t have do stuff for the sake of doing it “ ( I’m not saying they are first )
Maybe we need to do something else – which adds value – eg No Fault Found = User Error before someone gets hurt ( most of the time ) - lets count NFF rather than the number of items tagged or not tagged
I think most people who make a effort to post stuff on this list are on the same page – as biomeds we just seriously disorganised ( in fact biomeds [ and other healthcare people ] tend to be slow adopters and if we , as a group , were involved in the internet you would be pen pal [ remember those days ] )
http://en.wikipedia.org/wiki/Ignaz_Semmelweis
