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Equipment and technology


Using equipment and technology safely

Using equipment and technology


Male physician looking at multiple screensHuman factors engineering involves the study of ergonomics and how people use equipment and technology.

Case: Female with a laceration and thermal injury
Close up of female arm being bandaged by healthcare worker

Background

A patient puts her arm through a glass window. It is clear the wound requires suturing. A careful exploration reveals no foreign bodies and no significant neurovascular injury.

The doctor proceeds to suture the wound. After infiltration of local anaesthetic, a blood pressure cuff is used as a tourniquet. No draping is applied to the arm around the laceration.

Background continued

A lamp supplied by the hospital is switched on to provide illumination.  

The patient repeatedly alerts the physician and nurse that she is feeling discomfort and burning. The doctor who is suturing the patient attributes the patient's discomfort to the blood pressure cuff. The nurse moves the lamp on at least two occasions to respond to the patient's concerns.

When the suturing is completed a dressing is applied and the patient is discharged.

Outcome

When the patient returns for a dressing change two days later it is discovered she has significant necrosis due to a third-degree burn, and skin grafting is needed.

Subsequent investigation reveals the lamp is defective; it is missing a heat shield.

Think about it

  • What contributed to this patient's burn?
  • Can you think of ways this problem might be prevented?
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Causes of equipment failure:

  • design faults
  • improper or inadequate maintenance
  • damage due to mishandling
  • inappropriate use

Case: A 48-year-old woman with hearing loss
Close up of ear examination

Background

A 48-year-old female complains to her family physician about bilateral hearing loss.

On examination, the physician finds cerumen blocking the external canals of both ears. The physician recommends ear syringing and proceeds to do the procedure.

While pressure is being applied, the syringe suddenly breaks apart, and the plastic tip causes a puncture in the tympanic membrane.

Outcome

The physician discusses what has happened with the patient, apologizes, and refers her to an otolaryngologist.

The tympanic membrane perforation ultimately heals with conservative treatment and there is no permanent hearing loss.

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Experts giving opinions on these types of cases usually support physicians when:

  • The procedure is indicated.
  • The equipment is regularly maintained.
  • The equipment is checked to determine that it functions properly.
  • Reasonable precautions are taken to prevent injury.

Case: Transient neurologic symptoms treated with angioplasty
Female surgeon

Background

An interventional radiologist (IVR) is treating a patient for subclavian steal syndrome.

The doctor has extensive experience with the balloon angioplasty technique, but is using a new type of catheter for the first time. He encounters some difficulty inflating the balloon.

When asked, the nurse confirms that the protective sheath has been removed. After further manipulation the surgeon is able to inflate the balloon.

Months later the patient has to undergo surgery to remove the sheath which had not been removed — it had come off while in the artery and had remained there.

Outcome

The surgery required to remove the sheath was successful.

Lessons learned

Analysis of the reasons for this event revealed several problems:
  • The sheath was made of clear plastic so its presence wasn't obvious (the IVR was familiar with one that had a coloured sheath).
  • The IVR and nurse had not familiarized themselves with the new catheter.
  • The IVR accepted assurances the sheath had been removed, even though it could not be found.

Lessons learned continued

  • The nurse did not indicate she could not find the sheath as she assumed it had fallen under a drape or onto the floor.
  • When the balloon finally inflated, the IVR did not consider the possibility that his manipulations had allowed the sheath to come off intravascularly.

Subsequently, a new protocol for using the equipment was introduced and the need to change the sheath to coloured plastic was communicated to the manufacturer.

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Case: A problem with liposuction equipment
Surgical markings (guidelines) on female leg

Background

A woman undergoes liposuction of her lateral thighs.

Prior to starting the procedure, the plastic surgeon is aware the handle of the liposuction device has a history of problems and has previously been returned to the manufacturer for servicing on at least four occasions.

Early in the procedure, the plastic surgeon notes that the liposuction device is not functioning properly and the handle is becoming warm. He lies the device down with the handle on the paper drape covering the patient's left calf for approximately five seconds.

A burn results which eventually becomes full thickness.

Outcome

The burn ultimately heals, but the patient is left with a scar.

Lessons learned

Since the plastic surgeon was aware that the handle of the liposuction device had a history of problems, he should have:
  • been extra careful to keep the warm handle of the device away from the patient or not have used this particular device
  • asked the surgery clinic to replace the liposuction device
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Case: Failure to attend to malfunctioning office equipment
Female physician checking female patient's breathing

Background

A 30-year-old woman is reassessed by her family physician for worsening complaints of chest congestion, cough, and shortness of breath.

The patient's chest is clear on auscultation. Her oxygen saturation (SaO2) is 78%, which the physician attributes to a malfunction of the monitor rather than severe hypoxemia.

The physician prescribes antibiotics and orders a chest X-ray for a presumed diagnosis of pneumonia.

Outcome

When the patient returns one week later for persistent symptoms, her SaO2 is 73% and the chest X-ray report reveals marked abnormalities.

The family physician promptly refers the patient to a respirologist who diagnoses her with lymphangiomyomatosis (a rare pulmonary condition characterized by smooth muscle proliferation resulting in small airway and lymphatic obstruction) and secondary bilateral chylous pleural effusions, chylous ascites, and pulmonary hypertension.

Think about it

When the patient's SaO2 was only 78%, the family physician assumed it was due to a malfunction of the monitoring equipment rather than severe hypoxia.
  • How could the family physician have determined if the SaO2 reading was correct or the result of equipment failure?
  • What should the family physician have done about the SaO2 monitor and reading at this point?
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Case: Point-of-care guidance and alert not functioning properly
X-ray image of shoulder

Background

An emergency department (ED) physician reads a shoulder X-ray as normal for a patient who had fallen and injured his shoulder.

The patient is discharged home.

Three weeks later, the ED physician receives the X-ray report describing a complete subluxation of the shoulder.

The patient is notified and referred to an orthopaedic surgeon.

Lessons learned

So what went wrong?  
  • The hospital had an electronic system in place between the ED and the radiology department for radiological investigations.
  • When a radiologist reviewed an X-ray that originated from the ED, the ED physician's X-ray interpretation could also be viewed on the computer. If the diagnosis differed from the ED physician's, the radiologist would electronically notify the ED physician of the discrepancy.
  • There was a problem with the computer system and the ED never received the radiologist's notification.

Think about it

  • What systems have you worked with for follow-up of investigations?
  • How might this have been prevented?
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Case: When no point-of-care guidance or alert is set up
X-ray image of chest showing abnormality

Background

Neither the general surgeon nor the operating room (OR) team reviewed the preoperative chest X-ray prior to a patient undergoing an uneventful laparoscopic cholecystectomy.

Two years later, a chest X-ray reveals a large pulmonary mass.

A retrospective review of the preoperative chest X-ray indicates the mass was clearly present at the time of surgery.

Outcome

The patient subsequently dies from lung adenocarcinoma.

Think about it

  • Neither the surgeon nor the OR team reviewed the chest X-ray preoperatively.
  • The radiologist did not send a preliminary report of the chest X-ray to the surgeon.
  • The chest X-ray report was entered into the hospital computer system three weeks after the surgery.
  • There was no entry in the electronic health record to alert the physician that a report was available for review or sign off.
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In your career as a physician, you may have opportunities to contribute to improvements in the design of equipment.