After reading this scenario , In your opinion, is this situation due to an issue
ID: 239578 • Letter: A
Question
After reading this scenario , In your opinion, is this situation due to an issue with human engineering or was it due to an issue with equipment design?Please explain your answer thoroughly, using information from the scenario to prove your point.
What is the next step, in your opinion, to ensure that this situation does not happen again ? Box 2 Case study Two 4th year medical students stood next to the nursing station chatting about the ICU census. With the new hospital policies for admitting and transferring patients, it seemed as if they were constantly involved in moving patients into and out of the ICU rooms. This was the e f their first week in this intensive care medicine rotation. Just at that moment an unconscious patient was being brought into the ICU from a remote part of the hospital. He had been admitted 5 days earlier with worsening chronic obstructive pulmonary disease (COPD) and fever. Before his admis been living at home being cared for by his wife and visiting nurses for COPD and mild chronic heart failure (CHF). Sputum, blood, and urine cultures were inconclusive upon admission. The fever and increased white blood cell count had been reduced with empirical treatment with intravenous antibiotics. Initial physical examination and chest radiography revealed possible worsening CHF. ECG showed sinus tachycardia and right ventricular enlargement with no evidence of i were consistent with COPD and similar to the values at his last discharge. Subsequent fluid input and output data and daily examinations seemed to confirm worsening CHF since admission. He had several instances of ventricular arrhythmias in the previous 12 hours and it was determined that he needed more invasive and closer monitoring sion he had schemia. Blood gases For this intra-hospital transport he was receiving oxygen via a mask from a portable oxygen cylinder mounted under the transport bed. There were two peripheral intravenous lines delivering fluids through two infusion pumps. The transport moni- tor showed a blood pressure of 120/80 mm Hg and a heart rate of 72 bpm. Both students joined the transport personnel, nurses, and ICU fellow who were moving the gurney into the open ICU room. There was nothing unusual about the fact that many people in this crowded room were doing several things at once to move the patient and transfer lines and equipment. A transport nurse remarked how unusually stable this patient was during trans port One of the 4th year medical students had recently completed a month on the cardiology service. His attending (teacher) had constructively "counseled" him several times to treat the patient, not the "numbers". This student noticed and to the group that the patient had a respiratory rate of 24 beats/min. Given the stable BP and heart rate on the transport moni- tor, this tachypnea seemed out of place At nearly the same time the ICU nurse who was taking over the care of this patient hooked the leads up to the wall mounted cardiac monitor. Many in the room gasped in surprise to see the "real" heart rate of 140 bpm and BP of 80/60 One of the transport personnel realized she had seen this while working as an emergency medical technician (EMT): the transport monitor had been left in demonstration (demo) mode. Demo mode is a software program within the device that gen- erates data to continuously display waveforms and numbers that demonstrate the capabilities of the monitor device. It is often used during training. The former EMT pointed out the small "D" on the monitor screen to the team who were now assessing and preparing emergency treatment for this unstable patient. Over the next few hours the ICU team was successful in stabilizing the patient. Throughout these activities many of them ondere d aloud: "How could the transport team have been so careless. ?" Postscript Many interesting facts were later uncovered about how this hospital transported critically ill patients between units and other staffing issues. First, there was no overall staff shortage on the day of the event. It was found that the hospital had informally created special transport teams because some of the transport equipment was "tricky" to use. On that particular day, since there were more transfers than the transport team could handle, nurses and other personnel were called in to perform some of the work. The members of this particular team had received in-se However, in this event, this newly formed transport team was using the transport monitor device for the first time rvice training on the transport monitor in the past 2 years. It was not clear under what conditions the transport monitor was placed in demo mode. However, it was clear from review- ing the manual and talking to the biomedical engineering personnel that the monitor could stay in demo mode "forever". There was a small "D" in the lower right corner of the screen signifying this mode. Upon recreating the steps to place the device into and out of the demo modes, it was found that several unclea of the process on the device display. Although it was likely that this had happened to many others, only a few citations in the form of letters could be found in a Medline search.The main points of this event come from a real case, but it is not neces sarily a case from within the VA healthcare system. r steps were necessary. In addition, it was hard to follow the steps The details are taken from many cases from within and outside the VA healthcare system
Explanation / Answer
In my opinion, this issue is definitely due to Human mistakes and negligence. As a medical professional, general basic analysis of the patient with his past history and present complaints itself, one can identify the patient condition. As the patient is a COPD and CHF with other complaints of fever, right ventricular enlargement, sinus tachycardia showing stable signs is a big question. At this point, the transport system could be noticed and corrected the mistakes. Before connecting the monitor to the patient itself, the personnel should be checked it properly.
Transporting of a critically ill patient has several risks. As the hospital has special transport teams, sending of new personnel to transfer a critically ill patient is another big issue in this scenario. Even though there is a lot of transfers on that day, the transport team should handle it properly based on the patient condition and trained and untrained personnel. Trained team for critically ill patients and untrained personnel for transporting of stable patients. At least one trained personnel should accompany the patient while transporting would avoid the major issue.
Thirdly, the biomedical engineering should periodically check the monitor and to train all professionals who are all handling the equipment periodically. Updating of Knowledge-based technicals ( like showing off small D in the monitor) is under bio-medical responsibility. Not only the transport team all medical professionals within the hospital should have knowledge of handling the equipment will minimize a lot of errors.
To prevent this situation to happen again, The medical professionals should work on Knowledge-based rather than on focus on monitor and equipment. As the 4th year student said, treat the patient not the numbers is definitely true. Health professionals should use their presence of mind in addition to their knowledge and skills. The hospital should review their policies in transporting of the patient and in the ICU. The hospital should have a collaboration work where all the departments ( transport team, ICU, Physicians, nurses, Biomedical) should work as a team in treating the patient. Periodical updating of knowledge is necessary. As medical professionals, we should save the life of patients rather than creating them into critical. It is also against the ethical principles.