Transcript Fault Tree Analysis Negative Training Effect Incorrect post-

Fault Tree Analysis
Intravenous Infusion Simulation
Russell Bregman, Jon Grasman, Craig Lehocky,
Adam Scharl
Advisor: Dr. Joe Samosky
Negative
Training Effect
April 22, 2008
Revision 7
Feedback
system error
Unrealistic
Simulation
User Injury
A
B
C
Incorrect postsimulation
analysis
D
A
Improper flow rate
measurement
Incorrect visual
feedback
LED error
IV tubing
leak
Component
error
Incorrectly
programmed
calculations
Faulty flow
sensor
Design
error
Component
error
Programming
error
User error
Design
error
Component
error
Power system
error
Component
error
B
Training /
simulation process
disparities
Training / simulation
component
disparities
Infusion angle
limitation
Added flow
resistance
Design
Design
Calibration of
system
Extra
electrical
wiring
LED feedback
Design
Design
Design
Selecting
drug in
system
Flow sensor
Design
Design
C
Electric shock
Slip and fall
Faulty wiring
IV tubing leak
Incompatible
component
connections
Tangled
electrical
wiring
Design
error
Component
error
Design
error
User error
Design
error
Design
error
Insufficient
insulation
Design
error
Improper
electrical
grounding
Design
error
D
Incorrect volume /
concentration
calculation
Memory failure
Improper
interpretation of
data
User error
Software
malfunction
Hardware
malfunction
Programming
error
Incorrect drug
selection
Incorrect flow rate
measurement
Programming
error
Component
error
Design
error
Component
error
Design
error
User error