Analysis of infusion pump error logs and their significance for health care.

Analysis of infusion pump error logs and their significance for health care.
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输液泵错误日志分析及其对医疗保健的意义。

DOI:
10.12968/bjon.2012.21.sup8.s12
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发表时间:
2012
影响因子:
--
通讯作者:
H. Thimbleby
H. Thimbleby
中科院分区:
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文献类型:
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作者:
Paul Lee;F. Thompson;H. Thimbleby

文献摘要

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输液治疗是任何医疗机构中最大的实践疗法之一,输液泵每年在NHS中用于输送数百万次输液。飞机制造业从“黑匣子”中下载信息,以帮助设计更好的系统并降低风险;然而,输注泵的错误日志和数据日志却不能这么说。本研究下载并分析了一家大型急性病医院使用长达2年的131台输液泵的约360 000小时输液泵错误日志。工作人员必须管理260 129个警报;这约占总输液时间的5%,每年每台泵的成本约为1000英镑。本文描述了许多此类见解,包括许多技术错误、临床条件下某些警报的倾向、后勤问题以及基础设施问题如何导致警报条件增加。建议常规使用错误日志分析,结合适当的泵管理,以帮助识别改进的器械设计、使用和应用。
Infusion therapy is one of the largest practised therapies in any healthcare organisation, and infusion pumps are used to deliver millions of infusions every year in the NHS. The aircraft industry downloads information from 'black boxes' to help design better systems and reduce risk; however, the same cannot be said about error logs and data logs from infusion pumps. This study downloaded and analysed approximately 360 000 hours of infusion pump error logs from 131 infusion pumps used for up to 2 years in one large acute hospital. Staff had to manage 260 129 alarms; this accounted for approximately 5% of total infusion time, costing about £1000 per pump per year. This paper describes many such insights, including numerous technical errors, propensity for certain alarms in clinical conditions, logistical issues and how infrastructure problems can lead to an increase in alarm conditions. Routine use of error log analysis, combined with appropriate management of pumps to help identify improved device design, use and application is recommended.