Endoscope reprocessing has been identified as a complex procedure that, when completed incorrectly, can lead to patient outbreaks due to cross contamination. Most reported incidents cite human error as the cause, but little research to date has explored the human factors related issues surrounding reprocessing procedures. The purpose of this study was to interview experts in endoscope reprocessing to determine the most difficult steps and error prone tasks in the procedure as well as identify potential contributing factors to error. Relationships between tasks and contributing factors are examined and implications for future research are discussed.
Get full access to this article
View all access options for this article.
References
1.
AlfaM.J.OlsonN.DeGagneP. (2006). Automated washing with the Reliance Endoscope Processing System and its equivalence to optimal cleaning. American Journal of Infection Control. 34 (9), 561-570.
2.
CrandallB.KleinG.HoffmanR. (2006). Working Minds, A Practitioner’s Guide to Cognitive Task Analysis. Cambridge, MA: The MIT Press.
3.
HildebrandE.A.BranaghanR.J.WuQ.JollyJ.GarlandT.B.TaggartM.NguyenM.A.EpsteinD.R.Babcock-ParzialeJ.BrownV. (2010). Exploring Human Factors in Endoscope Reprocessing. Human Factors and Ergonomics Society Annual Meeting Proceedings, Health Care. 5, 894-898
JollyJ.HildebrandE.A.BranaghanR.J.WuQ.GarlandT.B.EpsteinD.R.Babcock-ParzialeJ.BrownV. (2011). Patient Safety and Endoscope Reprocessing: A Usability Test of the Reprocessing Procedure. Human Factors and Ergonomics in Manufacturing and Service Industries. (in press).
6.
MuscarellaL.F. (2006). Inconsistencies in Endoscope-Reprocessing and Infection-Control Guidelines: The Importance of Endoscope Drying. American Journal of Gastroenterology. 101(9), 2147-2154.
7.
NelsonD. (2002). Transmission of infection during gastrointestinal endoscopy. Clinical Update, American Society for Gastrointestinal Endoscopy. 9(3), 1-4.
8.
OfsteadC.L.WetzlerH.PSnyderA.K.HortonR.A. (2010). Endoscope Reprocessing Methods: A Prospective Study on the Impact of Human Factors and Automation. Gastroenterology Nursing. 33 (4), 304-311.
9.
Olympus Reprocessing Manual for 180 Series Endoscopes, (2005) Olympus Medical Systems CORP., GE4231 06
10.
Pennsylvania Patient Safety Authority (2010). The Dirt on Flexible Endoscope Reprocessing. Pennsylvania Patient Safety Advisory. 7(4), 135-140.
11.
ReasonJ. (1995). Understanding adverse events: human factors. Quality in Health Care. 4, 80-89.
12.
ReasonJ. (2000). Human error: models and management. British Medical Journal. 320 (7237), 768-770.
13.
RutalaW.A.WeberD.J. (2004). Reprocessing endoscopes: United States perspective. Journal of Hospital Infection, 56 (2), S27-S39
14.
Seoana-VazqueE.Rodriquez-MonguioR.CarlsonV.A. (2007). Endoscopy-related infections and toxic reactions: an international comparison. Endoscopy. 39, 742-746.
15.
Seoane-VazquezE.Rodriquez-MonquioR. (2008). Endoscope-related infection: relic of the past?Current Opinion in Infectious Diseases. 21, 362-366.
16.
SwainP.C. (2007). Deconstruction of the endoscope. Gastrointestinal Endoscopy. 65(4).
