ABSTRACT
INTRODUCTION As we stated in this book’s introduction, we want to give readers helpful insights into how to perform root cause analysis of medical device use errors. Sometimes, the root cause of a use error seems obvious. Consider the case of a nurse who misread a parameter value displayed on a patient monitor as “63” instead of “68.” You might jump to the conclusion that the numerals were too small given a reading distance of about 5 feet-that the 10 point (0.139 inch) high numerals were less than half the necessary height to read correctly from the given viewing distance based on human factors guidelines on making numerals legible (Figure 2.1).*
Indeed, undersized numerals might be the dominant root cause of the cited use error. But, is it the only cause? Might there be additional root causes that acted in combination to induce the use error but are not as self-evident?
