TABLE 3.
Factors Related to Ventilator-Associated Accidents
| Hardware | ||
| Power (OI) | 7 (20.6) | Nos. 7, 9, 10, 15, 22, 30, 33 |
| Degree of intuitiveness of the design | 4 (11.8) | Nos. 4, 19, 21, 30 |
| Transparency of operations (i.e., can users easily determine what the device is doing?) | 2 (5.9) | Nos. 16, 30 |
| Improper maintenance, testing, or repair | 2 (5.9) | Nos. 8, 22 |
| Default mode (poor feedback to users about default mode, inadvisable, unsafe, or unexpected default mode) | 2 (5.9) | Nos.13, 16 |
| Software | ||
| There are no rules for managing before, during, or after device-use (OI) | 25 (73.5) | Nos. 1, 2, 3, 4, 5, 6, 7, 8, 9, 13, 14, 15, 16, 19, 22, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34 |
| Policy or protocols are not consistent with manufacturing guidelines; failure to heed warnings or adhere to guidelines related to the safe use of a device | 9 (26.5) | Nos. 9, 12, 14, 17, 22, 25, 26, 30, 32 |
| There are rules, but there is a tendency to ignore the rules (OI) | 5 (14.7) | Nos. 2, 9, 12, 32, 34 |
| Introduction of devices without adequate education before implementation | 2 (5.9) | Nos. 1, 24 |
| Improper storage of devices | 2 (5.9) | Nos. 9, 14 |
| Existence of local rules (OI) | 2 (5.9) | Nos. 9, 14 |
| Introduction of devices without adequate assessment before implementation | 1 (2.9) | No. 2 |
| Organizational responsiveness to poorly designed or suboptimal devices and work-arounds | 1 (2.9) | No. 2 |
| Environment | ||
| Overlapping schedules, multiple tasks | 11 (32.4) | Nos. 6, 7, 12, 13, 20, 23, 24, 25, 27, 29, 30 |
| Use during patient transport or transfer | 8 (23.5) | Nos. 2, 4, 13, 17, 30, 32, 33, 34 |
| Staffing levels | 7 (20.6) | Nos. 4, 6, 7, 9, 22, 24, 34 |
| Environment changing (i.e., private room, administration from home) (OI) | 7 (20.6) | Nos. 1, 6, 11, 12, 14, 18, 28 |
| Not familiar devices (OI) | 5 (14.7) | Nos. 14, 17, 18, 33, 34 |
| Physical layout of care setting | 4 (11.8) | Nos. 9, 21, 30, 32 |
| Multiple types of devices adopted in the same department/hospital (OI) | 3 (8.8) | Nos. 19, 22, 31 |
| Liveware | ||
| Lack of awareness of risk or falsely low perception of risk | 26 (76.5) | Nos. 1, 2, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25, 26, 27, 29, 30, 32, 33 |
| Low attentiveness | 18 (52.9) | Nos. 1, 2, 5, 7, 9, 10, 12, 13, 16, 19, 20, 22, 24, 25, 26, 30, 31, 34 |
| Problem-solving skills | 12 (35.3) | Nos. 3, 4, 5, 9, 10, 15, 16, 19, 21, 22, 27, 31 |
| Poor ability to hear and interpret sounds, including alarms and other tones | 11 (32.4) | Nos. 3, 4, 5, 9, 12, 22, 25, 26, 30, 31, 34 |
| Lack of information-sharing among the staff members (OI) | 8 (23.5) | Nos. 1, 7, 10, 11, 13, 24, 30, 34 |
| Cognitive level of task (automatic or skill-based, rule-based, or knowledge-based tasks) | 6 (17.6) | Nos. 4, 5, 17, 19, 31, 33 |
| Degree of formal and informal training on the device | 6 (17.6) | Nos. 3, 5, 7, 25, 27, 34 |
| Personal interpretation of the meaning of actions and commands such as return or restart or enter | 5 (14.7) | Nos. 10, 15, 27, 30, 34 |
| Use in environments or care settings for which a particular device was not intended, but no awareness of potential risks | 5 (14.7) | Nos. 8, 15, 16, 17, 21 |
| Failure to detect a modified or malfunctioning device | 4 (11.8) | Nos. 4, 13, 22, 26 |
| Alert fatigue | 4 (11.8) | Nos. 9, 12, 30, 32 |
| Low degree of reporting among front-line staff experiencing difficulty with devices | 4 (11.8) | Nos. 5, 15, 21, 22 |
| Emotional state (anxiety, fear, stress level) | 2 (5.9) | Nos. 9, 33 |
| Failure to adhere to safety mechanisms | 2 (5.9) | Nos. 2, 33 |
| Liveware-liveware | ||
| Lack of awareness of risk or falsely low perception of risk | 18 (52.9) | Nos. 6, 7, 9, 12, 13, 14, 16, 17, 18, 22, 23, 24, 25, 26, 27, 29, 33, 34 |
| Problem-solving skills | 11 (32.4) | Nos. 3, 4, 5, 9, 10, 15, 16, 22, 25, 27, 28 |
| Lack of information sharing among staffs (OI) | 6 (17.6) | Nos. 1, 7, 10, 13, 24, 34 |
| Unexpected behavior of the patient (OI) | 5 (14.7) | Nos. 6, 11, 23, 25, 26 |
| Alert fatigue | 3 (8.8) | Nos. 9, 12, 32 |
| Lack of education and instructor for families (OI) | 2 (5.9) | Nos. 6, 17 |
| Lack of information-sharing among families (OI) | 1 (2.9) | No. 6 |
| Personal interpretation of the meaning of actions and commands such as return or restart or enter | 1 (2.9) | No. 25 |
Numbers show the assigned cases. These are items where multiple answers were allowed.
OI, original items that are not included in Mattox’s results.