Pa Pat Saf Advis 2016 Dec;13(4):171.
Saves, System Improvements, and Safety-II
Critical Care; Nursing
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“Saves, System Improvements, and Safety-II” is an occasional feature of the Pennsylvania Patient Safety Advisory, highlighting successes of healthcare workers in keeping patients safe. The Safety-II approach assumes that everyday performance variability provides adaptations needed to respond to varying conditions and that humans are a resource for system flexibility and resilience.

Exceeding “Routine” Checks of AEDs

A healthcare worker completing routine checks on an AED (automated external defibrillator) noted that the defibrillation electrodes (pads) in the emergency cart were not compatible with the AED. Further investigation revealed that multiple AEDs throughout the facility were affected. The correct pads were ordered and installed.

AEDs may be needed in emergencies when seconds count and delays in treatment can contribute to poor neurologic outcomes or even death. Imagine discovering an equipment mismatch in the middle of a resuscitation and having to scramble to find the right parts. Even though this healthcare worker was completing a routine—perhaps even a mundane—task, he or she went beyond just “checking the box” that all of the necessary parts were available and made sure that all of the parts fit together correctly. This person even went a step further, recognized that this mismatch could affect more than one AED, and checked on the other similar devices throughout the facility. These actions helped to ensure that if an AED were needed for an emergency anywhere in the facility, it would be fully functional.


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