Can a log of infusion device events be used to understand infusion accidents? Academic Article uri icon

abstract

  • Objective: This study sought to determine whether infusion deviceevent logs could support accident investigation.Methods: An incident reporting database was searched for infor-mation about log file use in investigations. Log file data from devicesin clinical use were downloaded and electronically searched forcharacteristics (signatures) matching specific function queries. Dif-ferent programming sequences were simulated, and device logswere downloaded for analysis.Results: Database reports mentioned difficulties resolving log filedata to the incident report and used log file data to confirm pro-gramming failures. Log file search revealed that, aside from alarmtypes and times, the devices were unable to adequately satisfy func-tional queries. Different simulated programming scenarios couldnot be easily differentiated by log file analysis.Conclusions: The device logs we studied collect data that are poorlysuited to accident investigation. We conclude that infusion devicelogs cannot function as black boxes do in aviation accidents. Logswould be better applied to assist routine operations.Key Words: patient safety, infusion devices, incident reporting,data recording, accident investigation(J Patient Saf 2007;3:208Y213)

publication date

  • January 1, 2007