Human reliability analysis - cardiac hospital case study with new applicability.
Safety 2011, June 12-15, 2011, Chicago, Illinois. Des Plaines, IL: American Society of Safety Engineers, 2011 Jun; :1-13
Cardiac care requires 24-hour monitoring of the condition of each cardiac patient's condition. This is achieved through evaluation and feedback of the patients' many critical physiological parameters. Increasingly, this monitoring is being accomplished through wireless technology. Technicians, located at remote monitoring stations, continuously monitor the many critical readings necessary to assess a cardiac patient's status. When an alarm comes in to the central monitoring station, technicians contact the nurses on the cardiac floor as necessary, and a nurse assesses and then addresses the patient's needs or potential cardiac condition. The case that motivated this study involved a patient whose cardiac condition was not addressed adequately by the hospital monitoring system. The analysis described in this paper included a complete ergonomic assessment, a task analysis, a workload and task engagement assessment, an evaluation of training, an analysis of equipment reliability, and a fault tree analysis to bring together a reliability analysis of the entire system. The results of the analysis showed that there was a probability of 1.63 x 10-2 that the system would fail again, meaning that another patient could experience an unaddressed cardiac condition. With so many interdependent system components, it is difficult to reduce this likelihood. However, through many physical, process, and task-based changes made by the hospital administration, as well as diligent oversight and regular performance data analysis, in the five years since the initial study, the hospital has not experienced another sentinel event to which the system failed to respond. This type of monitoring system and the required responses described herein can be compared to the development of upset conditions in a chemical or minerals processing plant. In both cases, there is a critical system that must operate properly in order to ensure well-being and safety.
Health-care; Cardiac-function; Heart; Biological-monitoring; Physiological-function; Physiological-measurements; Technical-personnel; Computer-equipment; Computers; Monitoring-systems; Monitors; Medical-monitoring; Medical-personnel; Medical-screening; Medical-services; Medical-equipment; Nurses; Health-care-personnel; Health-services; Equipment-reliability; Failure-analysis; Diagnostic-techniques; Diagnostic-tests; Warning-systems; Administration; Work-operations; Work-practices; Job-analysis
Safety 2011, June 12-15, 2011, Chicago, Illinois