Abstract
A never event is a serious and preventable error in healthcare. Wrong route drug administration into the arterial line can cause significant injury to the patients hand. Analysis of the incident data showed errors occurred during levels of heightened stress when medication was required to be given urgently, however during these circumstances healthcare workers did not seem to recognize the arterial line despite being coloured differently to standard venous lines. By using human factors design principles it was possible to develop a solution which prevents wrong route drug administration into the arterial line and does not interfere with normal clinical practice. We highlight that it was possible to eliminate a serious error in healthcare around the world.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Brunicardi, F.C., Anderson, D.K., Billiar, T.R., Hunter, J.G., Matthews, J.B., Pollock, R.E.: 12 Patient safety. In: Schwartz’s Principles of Surgery, 9th edn. The McGraw-Hill Companies Inc. (2010)
An organisation with memory. Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. Department of Health (2000)
Building a safer NHS: Implementing an organisation with a memory. Department of Health (2007)
The never events policy framework, an update to the never events policy. Policy 17891, October (2012)
Reason, J.: Human error: models and management. BMJ. 320, 768 (2000)
Design for patient safety. A system wide design led approach to tackling patient safety in the NHS. The design council. The Department of Healt (2003)
Kohn, L.T., Corrigan. J.M., Donaldson, M.S.: To Err Is Human, Building a Safer Health System Committee on Quality of Health Care in America. Institute of Medicine, National Academy Press (1999)
Problems with infusions and sampling from arterial lines. Rapid Response Report. National Patient Safety Agency. NPSA/2008/RRR006 (2008)
Sen, S., Chini, E.N., Brown, M.J.: Complications after unintentional intra-arterial injection of drugs: risks, outcomes, and management strategies. Mayo Clin. Proc. 80, 783–795 (2005)
Problems with infusions and sampling from arterial lines. Supporting information for the Rapid Response Report. National Patient Safety Agency. NPSA/2008/RRR006 (2008)
McLean, C.R., Cheng, K.S., Clifton, M.A.: Fatal case of accidental intra-arterial phenytoin injection. Eur. J. Vasc. Endovasc. Surg. 23, 378–379 (2002)
Durie, M., Beckmann, U., Gillies, D.M.: Incidents relating to arterial cannulation as identified in 7,525 reports submitted to the Australian incident monitoring study (AIMS-ICU). Anaes and Inten Care. 30, 60–65 (2002)
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2017 Springer International Publishing Switzerland
About this paper
Cite this paper
Mariyaselvam, M., Gupta, A., Young, P. (2017). Building Safety into Medical Devices: The Non-injectable Arterial Connector Preventing Wrong Route Drug Administration. In: Duffy, V., Lightner, N. (eds) Advances in Human Factors and Ergonomics in Healthcare. Advances in Intelligent Systems and Computing, vol 482. Springer, Cham. https://doi.org/10.1007/978-3-319-41652-6_27
Download citation
DOI: https://doi.org/10.1007/978-3-319-41652-6_27
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-41651-9
Online ISBN: 978-3-319-41652-6
eBook Packages: EngineeringEngineering (R0)