scholarly journals Root cause analysis of epidural spinal cord stimulator implant infections with resolution after implementation of an improved protocol for surgical placement

2019 ◽  
Vol 20 (4) ◽  
pp. 185-190
Author(s):  
Forest W Arnold ◽  
Sarah Bishop ◽  
David Johnson ◽  
LaShawn Scott ◽  
Crystal Heishman ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Operating Room ◽  
Surgical Site Infections ◽  
Root Cause Analysis ◽  
Hospital Epidemiology ◽  
Cause Analysis ◽  
Root Cause ◽  
Cord Injury ◽  
Vancomycin Powder ◽  
To Receive

Background: Placing a spinal stimulator for the purpose of restoring paralysed function is a novel procedure; however, paralysis predisposes people to infection. Preventing surgical site infections is critical to benefit this population. Objective: The objective of this study was to review the root cause analysis of postoperative wound infections by a hospital epidemiology team following implantation of epidural spinal cord neurostimulators in patients with chronic spinal cord injury. Methods: A team was assembled to review the case of every individual who had been enrolled to receive a neurostimulator at the facility. A root cause analysis was performed evaluating five categories: the patient; equipment; facility/environment; procedure; and personnel. Findings: The root cause analysis included 11 patients. Two patients became infected. Three others dehisced their wound without becoming infected. All patients were given preoperative antibiotics on time. A mean of 17 personnel were in the operating room during surgery. Vancomycin powder was used in the patients who either dehisced their wound or became infected. Conclusions: The root cause analysis provides guidance for other institutions performing the same novel procedure. This analysis did not reveal a direct association, but did generate several areas for improvement including increasing pre-surgical screening, cleaning transient equipment (e.g., computer screens), limiting traffic in the operating room, using new sterile instruments for each stage of the procedure, not reopening the back incision, not applying vancomycin powder, and using an antimicrobial envelope for the stimulator.

scholarly journals Severe Ventral Erosion of Penis Caused by Indwelling Urethral Catheter and Inflation of Foley Balloon in Urethra—Need to Create List of “Never Events in Spinal Cord Injury” in order to Prevent These Complications from Happening in Paraplegic and Tetraplegic Patients

2010 ◽  
Vol 2010 ◽  
pp. 1-5 ◽  
Author(s):  
Subramanian Vaidyanathan ◽  
Bakul M. Soni ◽  
Peter L. Hughes ◽  
Gurpreet Singh ◽  
Tun Oo
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Patient Safety ◽  
Root Cause Analysis ◽  
Urethral Catheter ◽  
Learning System ◽  
Cause Analysis ◽  
Root Cause ◽  
Cord Injury ◽  
Never Events

Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. We propose that a list of “Never Events” is created for spinal cord injury patients in order to improve the quality of care. To begin with, following two preventable complications related to management of neuropathic bladder may be included in this list of “Never Events.” (i) Severe ventral erosion of glans penis and penile shaft caused by indwelling urethral catheter; (ii) incorrect placement of a Foley catheter leading to inflation of Foley balloon in urethra. If a Never Event occurs, health professionals should report the incident through hospital risk management system to National Patient Safety Agency's Reporting and Learning System, communicate with the patient, family, and their carer as soon as possible about the incident, undertake a comprehensive root cause analysis of what went wrong, how, and why, and implement the changes that have been identified and agreed following the root cause analysis.

Root Cause analysis of SG tube ODSCC indications within the tube sheets of NPP biblis unit A

2011 ◽  
pp. 78-86
Author(s):  
R. Kilian ◽  
J. Beck ◽  
H. Lang ◽  
V. Schneider ◽  
T. Schönherr ◽  
...  
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

Rule Construction and its Execution for Root Cause Analysis

2012 ◽  
Vol 132 (10) ◽  
pp. 1689-1697
Author(s):  
Yutaka Kudo ◽  
Tomohiro Morimura ◽  
Kiminori Sugauchi ◽  
Tetsuya Masuishi ◽  
Norihisa Komoda
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

Root Cause Analysis Techniques Using Picosecond Time Resolved LADA

2014 ◽  
Author(s):  
Dan Bodoh ◽  
Kent Erington ◽  
Kris Dickson ◽  
George Lange ◽  
Carey Wu ◽  
...  
Keyword(s):  
Integrated Circuits ◽  
Picosecond Laser ◽  
Root Cause Analysis ◽  
Fault Isolation ◽  
Time Resolved ◽  
Cause Analysis ◽  
Root Cause ◽  
Design And Manufacturing ◽  
Multiple Interactions ◽  
Established Technique

Abstract Laser-assisted device alteration (LADA) is an established technique used to identify critical speed paths in integrated circuits. LADA can reveal the physical location of a speed path, but not the timing of the speed path. This paper describes the root cause analysis benefits of 1064nm time resolved LADA (TR-LADA) with a picosecond laser. It shows several examples of how picosecond TR-LADA has complemented the existing fault isolation toolset and has allowed for quicker resolution of design and manufacturing issues. The paper explains how TR-LADA increases the LADA localization resolution by eliminating the well interaction, provides the timing of the event detected by LADA, indicates the propagation direction of the critical signals detected by LADA, allows the analyst to infer the logic values of the critical signals, and separates multiple interactions occurring at the same site for better understanding of the critical signals.

Root Cause Analysis for Pin Leakage

2016 ◽  
Author(s):  
Zhigang Song ◽  
Jochonia Nxumalo ◽  
Manuel Villalobos ◽  
Sweta Pendyala
Keyword(s):  
Failure Analysis ◽  
Root Cause Analysis ◽  
Advanced Technology ◽  
Process Step ◽  
Cause Analysis ◽  
Hard Mask ◽  
Technology Node ◽  
Root Cause ◽  
Tools And Techniques

Abstract Pin leakage continues to be on the list of top yield detractors for microelectronics devices. It is simply manifested as elevated current with one pin or several pins during pin continuity test. Although many techniques are capable to globally localize the fault of pin leakage, root cause analysis and identification for it are still very challenging with today’s advanced failure analysis tools and techniques. It is because pin leakage can be caused by any type of defect, at any layer in the device and at any process step. This paper presents a case study to demonstrate how to combine multiple techniques to accurately identify the root cause of a pin leakage issue for a device manufactured using advanced technology node. The root cause was identified as under-etch issue during P+ implantation hard mask opening for ESD protection diode, causing P+ implantation missing, which was responsible for the nearly ohmic type pin leakage.

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