Hi Johnny John John
With respect to you observation that 70 % of the user errors are down to users ( which I agree with ) I would like to bring the following to your ( that’s all biomeds ) attention ( and I welcome comments)
A significant contributing factor to this high incidence of user errors can be directly attributed to biomeds undermining the technical competence gained by nursing staff trying to “fix” equipment . Hospital based biomeds are ideally suited to report details of user errors by make and department to clinicians so they can put mechanisms in place to address these very import alerts to user ability and competence ( or lack of it )
However I am not aware of any department in the world which has consistently done this over a period of years – we biomeds seem to be obsessed about tagging equipment rather than tackling life threating safety issues – see page 10 and 27 on this link
http://www.courts.qld.gov.au/__data/assets/pdf_file/0004/86755/cif-mcvey-os-20081128.pdfThe troubleshooting guide in the user manual has been designed to enable a competent user to deal with issues at the point of care – each and every time some one steps up to the plate to “fix” these user issues - everybody is better for it – fixing things or having a go is how we all learn – especially when getting to know a make and model ( if you have trained on PB840 it doesn’t make you a expert on a Drager or any other make)
Most clinicians expect to find clinical resources on the hospital intranet – the one missing resource is the medical equipment instructions and hence breaking the cycle of not referring to the user manual is an issue
However the good news is that I have solved this by creating a shared database of instruction manuals ( plus 20 000) which allow hospitals to ensure this information is available to all staff 24/7 – more than 200 hospitals use this ( UK and Australian ) (
http://bioclinicalservices.com.au/) – other than my obvious commercial interest – my mission is to target the 5 to 15 % of technically competent clinicians and remove the hurdles they need to go through to change the culture of pushing something aside and assuming it’s the device and not their ability . We need more technical skills at the bedside – after hours , weekends – a hospital is a 24/7 machine – not a 9 to 5 biomed department
For those of you who have access to the following publication I can recommend you download this article
Use error: a nurse's perspective.Dumais MM; Biomedical Instrumentation & Technology, 2004 Jul-Aug; 38 (4): 313-5 (journal article) ISSN: 0899-8205 PMID: 15338839 CINAHL AN: 2005027964
Thanks for your time and I look forward to comments