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
Machine:
AIDA
Scheduled Maintenance
Description
Central Cntrl - Inspect
exterior for damage
Central Cntrl - Inspect
power cords and strain
relief for damage
Central Cntrl - Clean interior
with vacuum and
compressed air
Central Cntrl - Clean fan
and fan filter
Central Cntrl - Verify correct
operation of controls and
indicators
Central Cntrl - Clean
exterior of unit
Central Cntrl - Clean
monitor
Central Cntrl - Clean and
vacuum keyboard
Central Cntrl - Cycle and
test alarms
Central Cntrl - Perform
electrical safety test
Insufflator - Inspect exterior
for damage
Insufflator - Inspect power
cord / strain relief for
damage
Insufflator - Clean interior
with vacuum and
compressed air
Manufacturer: Model:
Karl Storz
System 1
JAN
Serial Number: Tag Number:
KSA20765
KM6954
Month
FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
• 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.
AIDA
After Event
AIDA
4) Touchscreen
1) Ensure nothing is
behaves erratically 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
1) Keyboard and
Mouse not
responding
Action
1) Check to see if plugged in
2) Reroute to AIDA or PACs
video source
2) Pictures couldn't 1) Minimize AIDA program
print have to print to get to computer desktop
them manually
3) Video is black
and white
5) Display is locked Call Clinical Engineering
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
1) Call Clinical Engineering
• Common equipment
failures can now be
corrected by the
clinicians. The TPM
manual contains
simple step by step
instructions on how to
accomplish this.
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.
AIDA
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.
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.
AIDA
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.
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
AIDA
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
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.
AIDA
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.