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Dustin W. Ballard, MD, MBE; David R. Vinson, MD; and Dustin G. Mark, MD; May 2015
A man with a history of poorly controlled diabetes and pancreatic insufficiency was found unresponsive. Paramedics transported him to the emergency department, where a resident placed a right internal jugular line for access but was unable to confirm placement. The resident pulled the line, opened a second line insertion kit, started over, and confirmed placement with ultrasound. The patient went into cardiac arrest, and a chest radiograph noted a retained guidewire in the pulmonary artery.
Journal Article > Study
Fairbanks RJ, Caplan SH, Bishop PA, Marks AM, Shah MN. Ann Emerg Med. 2007;50:424-432.
This study used simulated resuscitation scenarios and found that a confusing user interface limited paramedics' ability to properly use two common defibrillator models. A related editorial discusses the challenge of uniting patient safety principles and usability.