If a healthcare worker makes a mistake using a piece of medical equipment and it causes harm to a patient there is usually a call for that person to be retrained (or suspended or dismissed)
If lots of different healthcare workers working in lots of different hospitals all around the country are all making exactly the same “mistake” as one another when using a piece of medical equipment this is a good sign that the design of the equipment is flawed.
Perhaps one of the best known examples of this is what has become known as the “switch of death” or the “hypoxia switch” on various anaesthetic machines. The mis-selection of this switch causes oxygen to be diverted away from the patient while they are connected to a ventilator (life support machine) during routine surgery. The ensuing shortage of oxygen causes the patient to become blue within minutes and if the cause is not recognised and rectified immediately the patient will die.
Despite awareness raising campaigns and repeated staff training incidents involving these switches continue to occur across the UK and despite reports to the manufacturers and to the MHRA machines with this design are still being sold to hospitals across the UK.
This is a very obvious case where (despite meeting national “standards”) design could be improved for safety but there are many other examples amongst which are oxygen cylinders that do not deliver oxygen when apparently full of oxygen and switched on, drug delivery pumps where dose delivery programming is prone to error (etc?).
Do you know how to tell if you have medical equipment like this in your hospital or indeed how to choose the safest medical equipment to purchase in the future?
Professor Chris Frerk, Consultant Anaesthetist and CHFG Trustee
