Human Factors in Healthcare: Level One by Debbie Rosenorn-Lanng

Author:Debbie Rosenorn-Lanng [Rosenorn-Lanng, Debbie]
Language: eng
Format: azw3
Publisher: OUP Oxford
Published: 2014-02-06T05:00:00+00:00

The idea of interlocking connections is to be adapted to make giving drugs intrathecally (into the spinal fluid in your back) safer. Only those drugs that are intended to go into spinal fluid will have the right attachment on the end of their syringe. This will hopefully very much reduce the chances of the wrong chemotherapy drug being injected into the wrong place (i.e. the drug that should be given into the vein will no longer be able to be given into the spinal fluid as it will not be possible to attach the syringe in which it is contained to the spinal needle).

I wonder also whether it might be possible to draw inspiration from this device in car manufacturing. Would it be possible to shape the nozzles at a fuel pump so that a diesel pump could only interlock with the cap on a car that takes diesel? This would potentially eliminate the whole wrong fuel wrong car scenario. I will leave you to ponder why I am contemplating this particular scenario. I digress.

I want you to consider for a moment any equipment that you work with. If you have time make a written list of all of the machines and tools. How familiar are you with any safety features? Do you know anything about the design of the equipment? Should you know? How could you find out more? How could you influence the future design of safety features? If you find yourself saying, ‘I wish it could just do …’ or ‘it would be better if …’, have you spoken to someone about your idea? Is it fit for purpose?

After the design phase is the manufacturing. Might there be a relevant step in any of the equipment or tools or machines or drugs or blood products or implants or consumables with which you are involved where a manufacturing fault might be important? How would you know there was one? What checks are in place to try and prevent it from having a significant impact on patient care? Do you know what checks the equipment should have been through? Or is that simply ‘someone else’s problem’? If so, who is ‘someone’ and how do you know they have done their job?

There are not infrequent episodes in industry of devices being recalled. In the last year I can think of a model of car, a pram, and a make of soft drink that were all recalled due to manufacturing errors. How would you know you had one? What would you do about it? How might you hear if something had been withdrawn or had an alert about it? How would you ensure this information was cascaded appropriately?

There has been a manufacturing issue with one of the anaesthetic drugs over a year ago. This led us to have to change the technique that is used for emergency anaesthetics. We had to adjust to using a different agent that behaves quite differently (it has a slower, less predictable onset). This involved modifying the whole technique.

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