Attitudes toward medical device use errors and the prevention of adverse events.

BACKGROUND The design of a device's user interface often contributes to the chance of a user making an error in using the device. However, there is evidence that most such errors that occur in practice are attributed solely to the user and that the primary method of error prevention is to retrain the user. Yet this attitude may decrease the quality of error reports and the use of more effective error prevention strategies. A qualitative study was conducted to assess health care employees' attitudes toward device use errors and the prevention of adverse events. METHODS Twenty-six health care employees from three hospital systems, including 11 device users and 15 nonusers who had participated in infusion pump purchasing decisions were given a scenario describing a device use error involving an infusion pump. Several open-ended questions assessed what they felt led to the event and how they would prevent the event from reccurring. RESULTS The top three reported types of factors leading to the adverse event, in decreasing order of frequency, were the user, pump design problems, and lack of training. The top three prevention strategies reported by the participants were retraining the user, redesigning the device, and telling the user to be careful. DISCUSSION These results suggest that health care employees still put too much emphasis on the traditional view of blaming and retraining the user.