As a result of consultation with a facility regarding a cluster of infections, Pennsylvania Patient Safety Authority analysts suspected a link between ergonomic design and the development of those infections. The analysts then queried the Pennsylvania Patient Safety Reporting System for data on the existence of other epidemiologic links, specifically targeting procedural systems, procedural environments, and equipment. Analysts identified two specific clusters of patient exposures that warranted further investigation and examined the narratives included in each of the event reports for both epidemiologic clusters.
The first cluster involved patients exposed to a contaminated endoscope. The narratives describe that several endoscopes had been sent out for repair. Loaner endoscopes (i.e., endoscopes loaned by the manufacturer) were placed into the system to temporarily supplement supply until the repaired endoscopes could be returned to service. The loaner endoscopes varied in design from the endoscopes the technicians were used to cleaning, as they contained an additional channel. Because the technicians were unfamiliar with the new equipment, the additional channel was not manually brushed (i.e., debrided) as part of the endoscope cleaning process.
The second cluster involved equipment purchased and retrofitted to an existing procedure room. The room was also used to perform other procedures and housed equipment related to those procedures, which in turn affected available space. The proceduralist had to change their surgical approach due to the room size and position of the equipment. This change in approach resulted in a cluster of ophthalmic infections.
The following Figure is typical of the continuum of processes institutions face when delivering care to a patient. The environment encircles and flows through the patient, the healthcare workers, and the equipment. All of the elements are interconnected and must be considered individually and as part of a larger whole in order to fully comprehend efficiency or inefficiency of design.
Figure. Ergonomic Factors and the Continuum of Care Delivery