Sunday, August 29, 2010

3rd seminar. Safety incident with the defibrillator gel in health centers. Root cause analysis

Problem description:

There are CPR training courses at primary care facilities in the 5th Primary Care area of Madrid. In reviewing the crash cart, the teacher finds in some facilities the presence of an alcohol gel bottle next to the defibrillator.

The gels for manual defibrillator must be alcohol free, because its use could burn patients.

Analysis of causes:

Professional causes: ignorance, not reviewing the composition of the gel, the defibrillator’s instruction manual and the provision of the crash cart, the coexistence of a semi-automated defibrillator that does not need gel.

Organizational causes: inexistence of a crash cart manager, rotative reviewing among the professionals, not separating the ultrasound gels (for ultrasonography and physical therapy) with alcohol.

Agents and resources: the trading house that provides the gel submits to the competitive acquisition a container identified with a sticker "for ECG and defibrillator”, but brought an alcohol gel, with the sticker "gel for ultrasound".

Working conditions: In some cases, the sonographic instrument and the crash cart are in the same room, and gels are exchanged.

Improvement actions:

Verification the competitive acquisition of the correct gel. Sample: the bottle says "ECG and defibrillator", without alcohol. Current product says "ultrasound transmission gel”, containing alcohol.

Appointment with the trading house, to clarify the supply of a product other than awarded.

Reporting the incident by fax, internal mail and e-mail to all professional; publishing on the website; notifying that there is defibrillator gel available in crash carts.

Sending the centers a correct gel container with a newsletter.

Edition of the book "Quality assurance in the use of health material and apparatus".
That includes a specific section on use and maintenance of defibrillators.

Although no damage has occurred, it is crucial the deployment of measures to prevent it in the future.

Oral presentation by Mercedes Martínez

+ Info: 20029.pdf

Posted by Fernando Palacio
English version by Erika Céspedes

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