Negative Training Effect Feedback system error Unrealistic Simulation User Injury Incorrect post- simulation analysis A B C D Fault Tree Analysis Intravenous.

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Presentation transcript:

Negative Training Effect Feedback system error Unrealistic Simulation User Injury Incorrect post- simulation analysis A B C D Fault Tree Analysis Intravenous Infusion Simulation Russell Bregman, Jon Grasman, Craig Lehocky, Adam Scharl Advisor: Dr. Joe Samosky April 22, 2008 Revision 7

Improper flow rate measurement A IV tubing leak Component error User error Incorrectly programmed calculations Design error Faulty flow sensor Component error Incorrect visual feedback LED error Programming error Design error Component error Power system error Component error

Training / simulation process disparities B Selecting drug in system Design Infusion angle limitation Design Added flow resistance Design Calibration of system Training / simulation component disparities Design LED feedback Design Extra electrical wiring Design Flow sensor Design

C Electric shock Faulty wiring Design error Insufficient insulation Design error Improper electrical grounding Design error Slip and fall Tangled electrical wiring IV tubing leak Component error Design error Incompatible component connections Design error User error Design error

Memory failure D Hardware malfunction Software malfunction Incorrect volume / concentration calculation Component error Design error Programming error User error Programming error Improper interpretation of data Incorrect flow rate measurement Incorrect drug selection Component error Design error User error