Causes Of Use Errors In Ventilation Devices-Systematic Review

A systematic review according to the PRISMA reporting standard was performed to identify causes of use errors in mechanical ventilators described in the literature. The PubMed search resulted in the inclusion of 16 papers. The errors described were systematically analyzed with regard to their causes and categorized in an adapted cause-and-effect diagram. The causes of use errors were related to specific usability issues and to the general condition that medical staff often work with different ventilators. When many devices are used, the different user interfaces are a source of use errors, since, for example, the same ventilation modes have different names. In order to avoid the identified causes for use errors in the future, this work offers manufacturers of ventilation devices design recommendations and the possibility to include the results in their risk management. In addition, standardizing user interface content across all ventilators, as in ISO 19223, can help reduce use errors.