2012 Volume 13 Issue 2 Pages 65-69
Incident reports involving medical tools such as infusion or syringe pumps ranked third in frequency among incident reports of the Postal Services Agency Hospital in 2009. We analyzed the reports involving infusion pump or syringe pump in terms of frequency and risk. Thereafter, we implemented practical training based on the analysis for the purpose of preventing incidents.
The incidence of “operation or set method error” was the highest in both frequency and risk, followed by “speed setting error” and “line management error.” After training, the number of incident reports involving infusion or syringe pump decreased by 54%, from 96 to 44 cases. The incidence of infusion or syringe pump in the non-participants (40/128, 31.3%) was significantly higher than that in the participants (4/115, 3.5%) of the training.
The results of questionnaires gathered from the participants indicated lack of knowledge about the pump was the chief cause of these incidents. Our findings suggest that practical training in consideration of the frequency and risk is effective for the purpose of preventing incidents.