Strategies to Prevent Recurrence of Incidents and Accidents Related to Medical Device Alarm Systems

Abstract

In medical institutions, medical device alarm systems are effectively utilized in case of emergency; however, incidents and accidents related to medical device alarm systems have occurred. In this study, we extracted incident and accident cases which occurred in relation to medical device alarm systems and investigated their occurrence factors and the strategies to prevent their recurrence.
Using the data search system on the web site of Japan Council for Quality Health Care, we extracted events which occurred in relation to medical device alarm systems, etc., and investigated the summaries of events, their occurrence factors and the strategies to prevent their recurrence.
We examined 116 events which had been identified as of April 2015. Identified events included 55 events occurring when an alarm operated and 61 events occurring without alarm signal.
There are various background and causal factors of events that are related to medical device alarm systems. This study suggested the importance of not only the management of human factors such as a lack of understanding of persons involved in the alarm system, etc., but also the need for the system service to identify the root causes of events, then to establish measures, and to carry out and evaluate them.