Emily Rose presentation at PICNet 2018 Conference 1 Critical Device Failure: Now What? PICNet Education Conference 2018 Emily Rose, MHSc, MPH Human Factors Specialist Quality & Patient Safety Vancouver Coastal Health March 9, 2018 Introduction â¢Medical Device Failures â¢Human Factors Engineering â¢Case Studies 2 Emily Rose presentation at PICNet 2018 Conference 2 â¢Manufacturing/Assembly error â¢Software glitch/hacking â¢Material selection â¢Contamination â¢Overstress 3 No Fault Found! 4 Emily Rose presentation at PICNet 2018 Conference 3 5 Investigating Causes of Failures 6 Emily Rose presentation at PICNet 2018 Conference 4 7 RootâCause Analysis: Whathappened, whyand what can be done to prevent 8 CPSI â Canadian RCA Framework, 2006 Emily Rose presentation at PICNet 2018 Conference 5 9 What is human error? 10 Emily Rose presentation at PICNet 2018 Conference 6 Inappropriate human behaviours that lowers levels of a systemâs effectiveness or safety, which may or...
Type: Media