Latent Errors – Equipment

Research has shown that 11% of NHS patients experience an adverse event, half of which are preventable, and a third of which lead to either serious complications or death.  Lord Hunt and Professor Rory Shaw have used this study to project annual totals of 400,000 preventable adverse events and 34,000 deaths. (From Improving Patient Safety – ECRI, 2001)

In this series of posts under the category ‘We Are Killing Our Patients’ we explore how, despite large funds and resources being put in to patient safety, the frameworks that exist in healthcare may actually be detrimental to the implementation of effective safety solutions.

(From Errors in Medicine by Gaylene Heard):
Errors may be classified into two broad categories: active and latent.

Active errors are the events occurring immediately before an incident or accident. These are the actions of the people on the front line interacting directly with the patient, such as doctors and nurses.

Latent errors are problems lurking within systems, which under certain conditions will contribute to an error occurring. Latent errors may lie dormant in systems for some time, but given a certain set of circumstances become evident. They are usually the result of decisions made by managers and administrators, designers of equipment and maintenance staff. In a sense, latent errors “set the scene” to make it more likely that an active error will occur.

For example, picking up the incorrect ampoule of a drug out of an anaesthetic drug trolley and administering it is an active error. That a potentially dangerous drug could come in an ampoule the same size, shape and colour as a more innocuous drug, and be stored directly next to it in a drug trolley, is a latent error, as it increases the likelihood of an error ultimately occurring.
Frontline staff are surrounded by latent errors and yet often feel powerless to remove them. The continued presence of Riotane tinted pink chlorhexidine and alcohol is a glaring example of this – there is no need for antiseptic solutions to be so indistinguishable. The statement ‘we need an adverse event to occur before the problem will be fixed’ frustratingly isn’t even true – we’ve had the severe adverse event. Effective frameworks to banish this product and others like it do not exist and so front line staff continue to work with these products in many hospitals.

Why is this?

Over the next series of posts we will delve deeper into why we continue to work with less than optimal equipment. Of particular concern is the purchase of a vastly inferior piece of equipment preventing the introduction of a much safer piece of equipment.

Equipment is often not designed with ergonomics in mind.

Fears of libel claims from manufacturers, job security, and reprimanding from healthcare bodies because appropriate (insert ineffective) channels haven’t been used often scare us away from openly broadcasting which equipment poses a latent error.

Perhaps the anonymity of patientsafe allows us to do this more comfortably, so here goes:

Riotane tinted pink chlorhexidine and alcohol

Airtraq – we have worked in institutions that have purchased this piece of equipment (perhaps because it’s cheaper) instead of a video laryngoscope. This places patients at unnecessary risk.

Colour change chemical method CO2 detectors such as the Easy Cap – to have something less than ideal places patients lives at risk. Most critical care doctors understand that formal capnography is the most important piece of monitoring (it provides an immediate assessment of airway, breathing, & circulation) – capnography monitors have become much more portable. We should get rid of chemical method CO2 detectors from environments where capnography can be used.

Draeger Primus non-beveled APL valves (Draeger we know you read our posts – please do the right thing and have your non-beveled APL valves recalled and replaced).

Central lines and attachments that open to air – we do not need them to and while we continue to use them we place patients at unnecessary risk of death from air emboli.

We know there are many more examples in the work place – please forward the latent equipment errors you’re aware of and we will add them to the list.

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