Documentation and investigation of missing health care equipment: The need to safeguard high priced devices in health care institutions

Abstract

Objective: Missing medical equipment in health care settings decrease productivity, increase spending to replace losses, and potentially endanger patient safety. By documenting and investigating the causes of these incidents, strategies to prevent future occurrences can be developed.Methods: As an example of this approach, we describe the inadvertent disposal of an expensive medical device during a randomized controlled trial (RCT) conducted within a medical facility. The incident was carefully documented and investigated shortly after it occurred. This information was used to develop targeted interventions to prevent further occurrences.Results: The device was a mattress overlay connected to a computer monitor that generated a continuous pressure image for use by nursing staff in the prevention of pressure injuries. An Environmental Services staff member disposed of one of these devices when the room of an enrolled patient was cleaned following their transfer to another unit. Miscommunication (or a misunderstanding of communicated information) and lack of awareness were identified as the main causes of this error.Discussion: By using the loss as a learning opportunity, the investigation of the incident led to strategies for preventing future occurrences. These included frequent training sessions for staff and improvements in signage. A detailed, factual and timely investigation of the events around the loss of armamentarium coupled with analysis on how to prevent future occurrences should be considered for all incidents involving high cost equipment.Conclusions: A standardized, non-judgmental approach to documenting and investigating the causes of costly equipment loss can lead to strategies for improved asset management and the prevention of further incidents of this nature.