An Estimate of Patient Incidents Caused by Medical Equipment Maintenance Omissions

Abstract

Patient incidents involving medical equipment are fairly common, but it is unclear how many of them are actually caused by maintenance omissions, i.e., improper or lack of scheduled and unscheduled maintenance. This question is important because hospitals have been allowed by The Joint Commission (TJC) to develop their own maintenance practice instead of following manufacturers' recommended frequencies and procedures. This study reports an attempt to estimate the magnitude of such incidents using the sentinel events database collected by TJC. Using worst-case assumptions, the estimates ranged 0.14–0.74 in 2011, which translates into .00011–.0006 per million equipment uses. These extremely low values were confirmed by a survey conducted by AAMI in which 1,526 participants reported no known patient incidents traceable to maintenance practice. Therefore, it seems unwise to mandate clinical engineering (CE) professionals to refocus their attention to manufacturers' maintenance recommendations versus active involvement in technology management and, especially, user training and assistance, to address the most frequent root causes of sentinel events.