Enhanced ICU Cable & Line Management System: Preventing Medical Errors

1. Cable and Fluid Line Management System Justine W. Carter Advisor: Richard Fries, Datex-Ohmeda

2. Medical Errors • 2000 report of the Institute of Medicine (IOM), entitled To Err Is Human: Building A Safer Health System • 44,000 to 98,000 people die in hospitals each year as the result of medical errors. • Medical Errors - eighth leading cause of death in this country— • higher than motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).

3. The Cost of Medical Errors is Rising • The IOM report • approximately $37.6 billion each year • about $17 billion associated with preventable errors. • no unified effort to address the problem of medical errors and patient safety, awareness of the issue has been growing.

4. Medical Error - Adverse Event • An adverse event is defined • "an injury caused by medical management rather than by the underlying disease or condition of the patient.” • 70 percent of adverse events found in a review of 1,133 medical records were preventable; • 6 percent were potentially preventable; • 24 percent were not preventable.

5. Need for new reorganized cable and line system in the ICU • When patient is transported, moved, or turned over • Cables become tangled and/or disconnected • Untangling cables is time consuming • Misidentification of devices connected • Results in medical errors

6. Dee Snyder, 2003

7. Dee Snyder, 2003

8. ICU equipment Considerations • IV pump - Water, sugar, vitamins, and medications are given • Ventilator - Oxygen • Feeding Tube - nose, throat, stomach, intestines • nasogastric (NG) tube - nose, stomach • removes food or liquids from stomach • Moniter wires - connected from patient to machine • heart, carbon dioxide,

9. Design System to Eliminate This Problem Multiparameter Cable Combines: ECG, SpO2 temperature

10. Neonatal Intensive Care Unit

11. Neonatal Intensive Care Unit

12. Neonatal Intensive Care Unit

13. Neonatal Intensive Care Unit

14. Design Generalized Multiparameter Cable • Combine Cables for • Heart Moniter • Cardiorespoiratry moniter • Pulse Oximeter • Carbon Dioxide Moniter • Respitory or Mechanical ventilator • IV Pumps • Design Retractable Cable

15. Proposed Design for Cable and Line Centralizer

16. Current Status • Researched similar devices • Contacted Dr. Bill Walsh,Neonatology • Preliminary sketch • Researching Retractable Cord

17. Future Work • Design final schematic • Research product materials • Research statistical information about medical errors • Re-Visit Medical Center • Research Retractable Cord System

18. References • Medical Errors: The Scope of the Problem. Fact sheet, Publication No. AHRQ 00-P037. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/errback.htm • http://space.interactiveinstitute.se/projects/iva-projektet/readymadedesign%20final.pdf • http://www.vh.org/pediatric/patient/pediatrics/copingwithintensivecareunit/index.html • Dr. Steve Robinson • Dr. Bill Walsh

19. Intensive Care Unit patients connected to many cables and fluid lines