Reducing Risk to Patient Safety with Custom Modification to Manufacturer’s Design

Abstract

This paper explores the experimental process of improving the design of an adapter to reduce patient safety risk. The built-in tether that secures the adapter to the multi-function cable for a defibrillator did not meet the clinical needs. As a consequence the adapter gets discarded and leaves the defibrillator in a state not ready to be used in an emergency situation. Three solutions were considered to minimize the risk. The final solution is a combination of two solutions which involves a set screw being added to the lock tab which prevents the tab from being pressed. This, in-turn, limits the ability to remove the adapter. A label was also added to add a visual that would prevent the removal of the adapter. The proposed solution was met with positive feedback from the clinical staff and was implemented across two units, ICU and ER. Since the implementation there have not been any complaints of missing adapters. This process opens up the opportunity to improve the design of other accessories as needed.