Iatrogenic Injury During Intraoperative Transesophageal Echocardiography: Implications for Medical Equipment Storage.

Background: Medical equipment failure is an underappreciated source of iatrogenesis. The authors report a successful root cause analysis and action (RCA) to improve compliance and decrease risks to patients during cardiac anesthesia care.

Methods: A quality and safety team of five content experts performed an RCA after an iatrogenic injury with transesophageal echocardiogram (TEE) probe insertion. The team used a fishbone diagram to identify causes and performed a Gemba walk to discuss probability of the different causes with key stakeholders. The team reviewed hospital policies and procedures as well as manufacturer manuals regarding best practices for maintenance and storage of TEE probes. The team created a corrective action plan centered on purchasing larger TEE storage cabinets, education of those who handle TEE probes, and implementing standard operating procedures. Effectiveness of the intervention was evaluated by analyzing frequency of TEE probe maintenance.

Results: The study period ranged from July 2016 to June 2021. TEE probes required maintenance 51 times, of which 40 (78.4%) occurred prior to the larger storage cabinet purchase, and 11 (21.6%) afterward. The number of TEE probes requiring maintenance per quarter was 4.4 (standard deviation [SD] 2.5) during the preintervention period and 1.0 (SD 1.0) during the postintervention period (mean difference 3.4, 95% confidence interval 1.0-5.9, p = 0.0006).

Conclusion: An extensive RCA resulting in a corrective action plan centered on compliance with manufacturer recommendations for storage of TEE probes resulted in fewer maintenance requests, which decreased the risk of iatrogenic patient injury from TEE probe failure during cardiac anesthesia care.