Pump Evaluation Form
Describe the issue (pos/neg) associated with the pump’s design or the process of using the pump.
What aspect of your job does this issue affect? (check all that apply): Pump set up Pump hook up in OR Pump use during surgery Pump tear down after use Maintenance Other __________________	Please explain:
What is the actual or potential impact that this issue may have? (check all that apply): Inefficiency (unnecessarily increases difficulty, complexity, or re-doing procedures) Distraction (takes attention away from primary task) Frustration (annoyed, stress, tension, etc.) Delay (things take longer than they should) Workaround (modification of equipment or procedure) Resource waste (use of materials or other personnel that should not normally be required Team coordination (interrupting others, or delay in responding to surgeon’s or other team member’s requests/needs) Procedural error (mistakes in decision making or failures of technique, etc) Patient inconvenience, discomfort or potential harm Other ___________________	Please explain:
What recommendation(s) would you make to fix the problem? Be as specific as possible. Draw a diagram if appropriate (space on back.)