Attitudes Toward Medical Device Use Errors and the Prevention of Adverse Events

摘要

The results show that participants see user errors, pump problems, and lack of training as the primary factors leading to the error. In comparison, a higher proportion of users than nonusers list user error as both a factor and the most important factor, whereas nonusers focus more on the pump problems and lack of training. These results provide evidence that health care employees are aware that factors other than the device user can lead to device use errors. However, the importance placed on user error, particularly among device users, suggests that the traditional view of blaming the operator is still prevalent. Although most participants appeared to be aware of systems factors, it is possible that many felt that it is the users' responsibility to overcome them—a view that reflects the traditional culture of shame and blame. On the other hand, the participants may simply have been responding to the reality faced by device users who have willingly accepted the responsibility of having to act within a poorly designed system.