Risk Management of Human- And System-Related Errors in the Pneumatic Tube System Operation at Dr. Hasan Sadikin General Hospital Bandung, Indonesia

Abstract

Pneumatics is a propulsion system which makes use of pressured air. Sixty percent of hospitals utilize this system due its positive benefit in saving transportation time and accuracy. In its implementation, problems may arise from procedural errors (or human errors) and from the PTS system itself (or system error) and are to be evaluated through a risk management. We aimed to determine the occurrence of human and system errors in PTS operation, as well as the risk classification based on the risk criteria scoring at Dr. Hasan Sadikin General Hospital (RSHS) Bandung in January 2018 -December 2019. This research is a cross-sectional descriptiveretrospective observational study. Data was collected from the reports on PTS operational problems within the 2-year period at RSHS. The data was then analyzed and processed using the SPSS 17.0 software, with which we quantified the obtained qualitative data. We found 26 reports of PTS repair, 12 (46.1%) of which were instrument-related (damage to vacuum, LAN, and compressor, as well as system overheat). 9 (34.6%) repairs were resulted from tube problems (jammed or broken caps in the PTS line), 4 (15.4%) were caused by damage to PTS pipes and line, and 1 (3.9%) by damage to the supporting spare parts. The best approach of prevention is to regularly change the instrument and tubes, manually deliver the samples, better manage the PTS personnel, and provide personal protective equipment. The recorded damage to the PTS system at RSHS was entirely caused by system errors. There was also a human error aspect in the tube shipping but it was not recorded.