Reducing Medical Errors with High Risk Low Use Devices

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Medical errors affect patients, staff (nurses in particular) and the hospital itself. Incorrect administration of (or failure to administer) medication, as well as equipment misuse may harm patients or even cause death. In turn, nurses who are directly responsible can be reprimanded, suspended, or terminated. Some may even face lawsuits in the event that the patient’s family chooses to pursue legal action for negligence. As for the hospital, budget and reputation is directly affected in all these scenarios.

While ineffective technology, such as defective design or programs may also cause such errors, the human-factor is to blame in most cases. In fact, the human-factor was the most frequent cause of medical errors based on a research in 2011 to 2013.

“Human-factor is the most frequent cause of medical errors based on a research in 2011 to 2013.”

Why Medical Errors Occur

Adverse effects when using new medical devices, processes and other related technology typically occur as a result of only two major concerns: the device or process itself, and the user.

Device Factor

Poor device design or programming may potentially lead to a handful of often innocuous errors.

Human Factor

User issues, on the other hand, are far more varied and prevalent. Some of these include fatigue, stress, insufficient training, and memory concerns. Errors related to retention most often occur with use of high-risk, low-use medical devices. People naturally tend to forget how a piece of equipment functions when they do not use it frequently. Stress and fatigue affect cognitive function, causing blunders at work.

Physical factors, like poor lighting, may also cause a hospital staff to misread instructions and misinterpret data.

How to Address Medical Errors

Errors related to  faulty functionality or program must be redirected at the manufacturer level through government intervention, with the cooperation of hospitals, as well as staff. This is why the Food and Drug Administration (FDA) encourages reporting of such concerns through related organizations like the Medical Product Safety Network (MedSun) or through the FDA website. MedSun relays product issues collected from hospitals to the manufacturer through a simple process. Defective items are removed and properly tagged before being sent back  for replacement or repair. The FDA may even elect to recall products which are consistently reported as faulty.

Medical devices should comply with FDA standards, following various factors of quality consideration, including reliability, safety, functionality, efficiency, and ergonomic design in some cases.

“The Food and Drug Administration (FDA) ensures patient safety by assigning strict guidelines to manufacturers of medical devices.”

The human-factor, on the other hand, can be addressed using various means.

Stress and Fatigue

Mistakes committed due to fatigue or stress are both a personal and work concern. Medical jobs are known to be stressful, with shifts lasting 12 hours or more per day. Consequently, it is expected for employees in this industry to deal with stress on a personal level so it doesn’t affect their performance. The employer (in this case, the medical facility) can also contribute by ensuring that scheduling isn’t too overloaded for each staff member, holidays and vacation time must be approved, and regular team building events should be organized.

All other preventable issues, such as mediocre lighting or ventilation and other physical factors should also be promptly resolved.

Insufficient Training

While it is imperative that all high-traffic areas are covered throughout all shifts, scheduling should still include training, particularly when new technology is introduced into the hospital. Blocking time for this purpose will prevent errors by ensuring that everyone knows how to properly use devices and complete procedures.

Comprehensive training isn’t limited to the usual introduction. It’s intended to cover these specific points:

  • Benefits of the device for patients, medical practitioners and the facility itself
  • Proper usage of the device
  • Manufacturer’s specific instructions, which include labels, warnings, expiration dates, contraindications and possible complications or concerns when product is mishandled
  • Comparison with related items or materials 

Training Challenges

In a busy hospital setting, blocking time to accommodate training sessions for several employees can affect staffing, but limiting the number of trainees per block time can be costly, due to increased use of conference rooms and audio/visual materials. Other than budget concerns, traditional training faces more challenges (particularly for participants), including limited attention span, distractions, and retention. The latter is most evident for devices and processes which are not frequently utilized.

“Medical device training challenges can be resolved through just-in-time training.”


Just-in-Time Training

Just-in-time training, or JITT, is a powerful tool used in many high reliability organizations. The Joint Commission has stated that traditional training techniques are not sufficient in producing zero-harm environments.. To that end, just-in-time training can augment traditional education with on-demand guidance at the point of care, allowing providers to rely less on their memory, while promoting accuracy and effectiveness, and reducing risks associated with erroneous usage of various devices – especially those which are high-risk, low-use.

Tine Health

Tine Health offers an effective and affordable solution that has been proven to reduce hospital error rates by over 50% in less than 6 weeks. Tine has been used to provide just-in-time training for high-risk, low-use medical devices, as well as healthcare documentation. Learn more at

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