Before Event• Prior to the event,

there was no way for clinicians to communicate if equipment was in good working order. Small equipment issues went unaddressed and often led to larger problems.

After Event• Green side provides

sequence of Autonomous Maintenance steps to keep machine functioning properly. Green side exposed means the machine is fit for use.

After Event• The red side of the

card allows clinicians to signal that equipment is not in proper working order. The most common failures are listed to eliminate diagnosis time needed by clinical engineering.

After Event

• Red side exposed means equipment is unfit for use. All common errors are listed on the red side. Users denote reason for equipment failure and circle where failure is occurring on the diagram

After Event• As one of the

deliverables, the team created a TPM manual for each machine which included guides for Operations, Schedule Maintenance, Trouble Shooting , and Critical Spares Replacement.

After Event• Prior to TPM implementation,

scheduled maintenance logs were heavily text based and difficult to understand. The team designed a visual scheduled maintenance log based off of one found in an car maintenance manual. Now all team members know when equipment will be out of service.

Machine: AIDA

Manufacturer:Karl Storz

Model:System 1

Serial Number:KSA20765

Tag Number:KM6954

Scheduled Maintenance Description

MonthJAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC

Central Cntrl - Inspect exterior for damage x Central Cntrl - Inspect power cords and strain relief for damage x x x Central Cntrl - Clean interior with vacuum and compressed air x x Central Cntrl - Clean fan and fan filter x x x Central Cntrl - Verify correct operation of controls and indicators x x Central Cntrl - Clean exterior of unit x x Central Cntrl - Clean monitor x Central Cntrl - Clean and vacuum keyboard x x Central Cntrl - Cycle and test alarms x Central Cntrl - Perform electrical safety test x x Insufflator - Inspect exterior for damage x Insufflator - Inspect power cord / strain relief for damage x Insufflator - Clean interior with vacuum and compressed air x

After Event• Common equipment

failures can now be corrected by the clinicians. The TPM manual contains simple step by step instructions on how to accomplish this.

AIDA 4) Touchscreen

behaves erratically1) Ensure nothing is touching or near touchscreen

2) Clean touchscreen Instructions: If error cannot be resolved with

sheet then call CE and check appropriate box on equip status card

Problem Action

1) Keyboard and

Mouse not responding

1) Check to see if plugged in 5) Display is locked Call Clinical Engineering 2) Reroute to AIDA or PACs

video source

2) Pictures couldn't

print have to print them manually

1) Minimize AIDA program to get to computer desktop

6) Can't take pictures

1) Confirm there's an endo image on display (not blue screen)

2) Open AIDA save

procedures file 2) Ensure AIDA is on (green

is on, yellow is off)

3) Select patient file you

need to print 3) Ensure patient name and

ID number is filled out

4) Select Internet Explorer

icon and print 4) Select "endo camera" for

AIDA Input Select

3) Video is black and

white1) Call Clinical Engineering

AIDA

Before Event• Prior to the event

the staff were unfamiliar with the proper procedure for replacing critical spares on the machinery. As a result the Clinical Engineering staff were called for simple swapping of machine parts or changing batteries.

After Event• The team created

documentation and processes around the replacement of critical spares. This among other documented processes were included in the TPM manual.

AIDA

Before Event

• Cords often cross crossed the OR floor creating opportunity for equipment failure.

Before Event• Improper cord and

foot pedal management caused many false equipment alarms.

After Event

• Convenient hooks were put in place for better cord and pedal management. Now clinicians can properly manage cords and pedals which used to be the source of many more serious equipment issues.

AIDA

Before Event• On off switch at

knee level caused loss of power during procedures. All captured images would be lost

• Poor placement of PC contributed to accidental kicking of power cords causing issues during surgery

After Event• Guard placed on PC

on/off switch to prevent accidental turn off during procedure

• PC’s relocated to prevent accidental removal of cords

AIDA

Before Event• Prior to the event

there was no designated location to place broken equipment that required service. As a result broken equipment would remain in service.

After Event• The team selected

and cleared an area and visually identified drop off locations where broken equipment is stored and removed from circulation. Clinical Engineering monitors these locations at least daily.

AIDA