Cause of Device-Related Incident
Device factors; Support system failures; User errors

Clinical Specialty or Hospital Department
Cardiology / Cardiac Catheterization; CCU / ICU / NICU; Clinical/Biomedical Engineering; CSR / Materials Management; Emergency Medicine; Nursing; OR / Surgery

Device Factors
Device failure

Document Type
User Experience Network (UEN) reports

Mechanism of Injury or Death
Misdiagnosis; Monitoring failure

Support System Failures
Improper storage

Tampering and/or Sabotage
*Not stated

User Errors
Abuse of device

UMDNS
Electrodes, Electrocardiographic [11-439]

ECG Electrodes: Use on Resuscitation Carts



User Experience Network™ [Health Devices Feb 1993;22(2):97-8]

Hospital

Our hospital is currently using pregelled electrodes in packages of 25 for resuscitation carts. The electrodes are placed on the electrode leads and left there until needed for a code. We have had occasional problems with noisy ECG signals during codes. We are concerned that the electrodes may be drying out, but the nurses insist on having electrodes preattached to reduce delay and to reduce costs compared with using electrodes packaged in threes or fives. What does ECRI recommend?

ECRI

It is essential that medical devices, including ECG electrodes, function properly and not hamper resuscitation efforts in life-and-death situations. Leaving the electrodes attached to the leads may result in drying, which would cause delays as the staff attempts to obtain an adequate trace, assesses the ECG with a poor-quality trace, or replaces the electrodes. Furthermore, electrodes removed from the bag may also have dried out, resulting in further delays while new electrodes are sought.

To reduce steps and increase response speed, you can obtain the initial ECG through the paddles; the patient can then be defibrillated, if needed, and the electrodes can be applied later.

If the current practice is continued, then electrodes must be replaced within their expected lifetime. You would also need to ensure that they are replaced on schedule.

The increased cost of using electrodes prepackaged in threes or fives will not be significant for such a low-use application. Taking into account the need to frequently replace dried-out electrodes, buying packages of 25 may not even offer any cost savings. In any case, the speed in obtaining the waveform and the quality of the waveform are much more important than cost issues.

UMDNS Term

Electrodes, Electrocardiographic [11-439]

Cause of Device-Related Incident

Device factor: Device failure

User error: Abuse of device

Support system failure: Improper storage

Mechanism of Injury or Death

Misdiagnosis; Monitoring failure


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