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Cases & Commentaries
- Web M&M
Vinod K. Bhutani, MD, and Ronald J. Wong; October 2017
A newborn with elevated total serum bilirubin (TSB) due to hemolytic disease was placed on a mattress with embedded phototherapy lights for treatment, but the TSB continued to climb. The patient was transferred to the neonatal ICU for an exchange transfusion. The neonatologist requested testing of the phototherapy lights, and their irradiance level was found to be well below the recommended level. The lights were replaced, the patient's TSB level began to drop, and the exchange transfusion was aborted.
Journal Article > Study
Laxmisan A, Malhotra S, Keselman A, Johnson TR, Patel VL. J Biomed Inform. 2005;38:200-212.
Using the concepts of "sharp" and "blunt" ends of practice, this article explores health professionals' differing opinions on biomedical device-related errors. Investigators requested that study participants express their views on events surrounding three true-error scenarios. Analysis of the transcribed responses revealed that interpretation varied widely between groups. While clinicians focused on clinical and human factors, biomedical engineers focused on device-related issues, and administrators emphasized documentation and training. The authors conclude that individual expertise largely mediates an error analysis, as no single interpretation provides a comprehensive view of all contributing factors.
Kerber R. The Boston Globe. June 23, 2005;Business section:E1.
This article reports on problems with medical devices and discusses whether manufacturers should directly notify patients regarding defects.
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; August 29, 2006.
This news release announces a seizure of infusion pumps that have a "key bounce" defect that could result in over-infusion of medication.
Journal Article > Study
Alemzadeh H, Raman J, Leveson N, Kalbarczyk Z, Iyer RK. PLoS One. 2016;11:e0151470.
Using an automated natural language processing tool, this retrospective study evaluated adverse events related to robotic surgery reported between 2000 and 2013. Device malfunctions contributed to many incidents, thus understanding these technical difficulties will be important for avoiding future harms.
Journal Article > Review
Bach TA, Berglund L, Turk E. BMJ Open Qual. 2018;7:e000202.
Alarm fatigue limits the utility of physiologic monitoring devices intended to keep hospitalized patients safe. The authors conducted a literature review and interviewed experts to identify best practices to optimize device alarms. They present a step-by-step guide to alarm improvement that incorporates a human factors engineering approach.
Mohr H, Weiss M. Associated Press. November 27, 2018.