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PSNet: Patient Safety Network
Book/Report

Medical Device Use Error: Root Cause Analysis.

Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.

Applying human factors engineering to examine mistakes associated with medical device use can lead to valuable learning opportunities. This publication discusses equipment use errors and provides information about utilizing root cause analysis (RCA) to identify weaknesses in device design that enable those mistakes. The book includes examples of RCAs to illustrate how the method can uncover flaws that contribute to error in various situations.