[Patient endangerment due to device diversity? : Discussion of a risk factor based on the results of two surveys of German hospitals].

Discussion of a risk factor based on the results of two surveys of German hospitals].
Anaesthesist. 2018 May 25;:
Authors: Lange K, Brinker A, Nowak M, Zöllner C, Lauer W
Abstract
BACKGROUND: The Federal Institute for Drugs and Medical Devices (BfArM) was notified of an event in which it was not possible to sufficiently ventilate a patient suffering a severe asthma attack. It turned out that the ventilation pressures used by the device for pressure-controlled ventilation were below the values set by the user, which the user was not aware of. The ventilation pressures chosen by the user exceeded the preset alarm limits of the ventilator. This pressure and alarm management significantly differed from that of other ventilators used in the hospital. This and similar incident reports suggest that safely operating medical devices for anesthesia and intensive care may be impaired when different models of a device are used within a hospital. If different models are used, more device information needs to be stored in memory. Existing knowledge on human memory suggests that the more individual memory items (e. g. different operating rules) are stored, the greater the risk of memory interference and hence of impaired retrieval, particularly if the different items are associated with overlapping retrieval cues. This is the case when different devices are used for a single functional purpose under identical or similar circumstances.
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Source: Der Anaesthesist - May 25, 2018 Category: Anesthesiology Authors: Lange K, Brinker A, Nowak M, Zöllner C, Lauer W Tags: Anaesthesist Source Type: research