Using the information provided in the attached case study, provide answers to the following: a) Explain the nature of the problem/issues described in this case. b) Propose a solution to the problem identified in part a, using ergonomic principles/techniques covered in this module.

Karen Nessen checked the EKG electrodes taped to the chest of the four-year old girl and ran the lead across the starched white bed sheet to the upper corner of the mattress. All she had to do now was plug the lead into the cord from the heart monitor machine sitting nearby at bedside. Karen and the other staff would then be able to monitor the little girl's condition while they were down the corridor at the nurse's station. An alarm would sound if the machine detected a significant change in the rhythm or pace of her heart. Karen, like the other nurses and technicians there at Children's Hospital in Seattle, treated dozens of young patients every day. Some of the cases were simple. Some, like this little girl's, were complex. But they all brought forth the extremes of emotion one has when treating the young. One minute you experienced the joy of helping a sick or injured child regain her health, and the next you might suffer the pain that accompanies failure and Joss of hope. This particular little girl had spent much of the four short years of her life combating a number of significant birth defects. She had fought many difficult battles in the past and would have to fight many more in the future. Everyone at the hospital was determined to provide her every opportunity to overcome her handicap.

Karen pulled the sheet up and folded it back neatly over the girl's small chest. She looked much more comfortable now that everything had been taken care of and the bed was straight. Not one to miss the details, Karen then reached down to the guard rail on the side of the hospital bed and lifted it upward. The metal bars made a satisfying click as they locked into place. There would be no danger of the patient falling out of the bed as she slept. All that remained was to plug the lead from the electrodes taped to the little girl's chest into the cord from the heart monitor machine. Karen picked up the lead resting near the comer of the mattress and looked down for the connecting cord. She paused for a moment to sort things out. Another machine was next to the heart monitor at bedside. It was a portable intravenous (IV) pump with all of its assorted cables and lines. Ah! There was the cable, hanging down near the side of the heart monitor. She bent over and grasped the end of the cord with her right hand and brought the two pieces together to connect them. The cord in her left hand terminated with a circular six-pin connector frequently used on EKG leads. It had to be held in the proper orientation when plugged into the receiving end of the cable from the heart monitor. It wouldn't fit into the receiving end unless it was held in just the right way. Karen lined up the two ends and started to push them together.

There was not even a remote possibility in Karen's mind that the cord in her right hand was from anything but the heart monitor machine. After all she handled dozens of small machines every day, and they all seemed to have different types of connectors. These unique connectors certainly made it easier to find the pieces that were supposed to fit together. More important, it made it nearly impossible to connect two things that were never meant to be connected. Or such was the intent. Little did she know that the cord in her right hand was from the nearby IV pump and not from the heart monitor. Its size and shape were similar to the cord from the heart monitor, and the connector had slots that matched reasonably well with the sixpin termination on the EKG electrode lead taped to the child's chest. The similarity might not have been so critical had the IV pump not been one of the portable models that could run off a battery or wall current. Accordingly, it had a detachable power cord for portable battery-powered operation. It was this cord that she had mistakenly grasped. Karen had no means of knowing that the cord in her right hand was a live electrical circuit and that it carried the full operating current of the IV pump!

In that dreadful moment Karen Nessen plugged the two connectors together and a lethal current of electricity streamed through the cord of the IV pump, through the errant connection, down the lead and one of the electrodes attached to the girl's chest, through her heart, and back to the IV pump via the other electrode and lead. The reaction was immediate, and Karen separated the two cords within moments of realizing what had happened. Karen and other members of the staff administered cardiopulmonary resuscitation to the girl during the terrible minutes that followed, but they could not revive her. A hospital spokesman stated to the press shortly thereafter: "At this time it looks like this is just a human error which is fairly tragic."