Life-threatening Events in Respiratory Medicine: Misconnections of Invasive and Non-invasive Ventilators and Interfaces^[*]

 

 Permissions and Reprints

Abstract

Purpose: Both the parallel use of intensive care unit (ICU)-ventilators and ventilators dedicated to non-invasive ventilation (NIV), as well as the construction of some expiratory valves in single circuit breathing tubes may lead to misconnections which are potentially fatal for the patient.

Methods: We demonstrate first a case of a misconnected expiratory valve in a patient with invasive home ventilation. In a second case, the mistaken connection of a non-invasive ventilator to an endotracheal tube leading to carbon dioxide (CO₂)-rebreathing is demonstrated. A third case describes a patient with home non-invasive ventilation who had been delivered a non-vented mask out-of-hospital, likewise leading to CO₂-rebreathing.

Conclusion: Human error is the main reason for critical incidents in medicine and the most serious unintended events often involve mechanical ventilation. A regular instruction of medical staff and patients is necessary. The demonstrated misconnections are examples of latent errors “waiting to happen”. To prevent these errors from being made in the future, technological solutions similar to the aviation effort to improve safety are needed.

Zusammenfassung

Hintergrund: Die Kompatibilität verschiedener Beatmungssysteme untereinander ist problematisch und kann zu Zwischenfällen führen. Dies betrifft sowohl die parallele Verwendung von Ventilatoren für invasive wie nicht-invasive Beatmung (NIV) als auch Beatmungszubehör (Tuben, Ausatemventile).

Methode: Anhand von 3 Fallberichten werden Beatmungszwischenfälle durch Kompatibilitätsprobleme demonstriert.

Ergebnisse: In einem ersten Fall berichten wir von einer Patientin mit außerklinischer Beatmung, die sich nach Schlauchdiskonnektion fälschlicherweise an die Ausatemöffnung des Exspirationsventils rekonnektiert hat. Im zweiten Fall führte die fälschliche Konnektion eines NIV-Beatmungsgerätes an einen Endotrachealtubus zur CO₂-Rückatmung. Der dritte Zwischenfall beschreibt einen Fall, bei dem ein Patient mit nicht-invasiver Heimbeatmung versehentlich mit einer Maske ohne Ausatemventil versorgt wurde.

Schlussfolgerungen: Menschliche Fehler sind ein Hauptfaktor für kritische Zwischenfälle in der Medizin und die gravierendsten Ereignisse betreffen die Beatmungsmedizin. Bei den hier gezeigten Möglichkeiten zur Fehlkonnektion besteht konstruktionsbedingt stets die Gefahr, dass die Fehler auftreten. Neben intensiver Schulung von Patienten, Angehörigen und medizinischem Personal halten wir auch technische Lösungen für erforderlich.

^* Contents of this article have been reported in part at the annual meeting of the German respiratory society April 2011 in Dresden.

• References

• 1 Cox CE, Carson SS, Govert JA et al. An economic evaluation of prolonged mechanical ventilation. Crit Care Med 2007; 35: 1918-1927
  CrossrefPubMedGoogle Scholar
• 2 Needham DM, Bronskill SE, Calinawan JR et al. Projected incidence of mechanical ventilation in Ontario to 2026: Preparing for the aging baby boomers. Crit Care Med 2005; 33: 574-579
  CrossrefPubMedGoogle Scholar
• 3 Nava S, Hill N. Non-invasive ventilation in acute respiratory failure. Lancet 2009; 374: 250-259
  CrossrefPubMedGoogle Scholar
• 4 Crimi C, Noto A, Princi P et al. A European survey of noninvasive ventilation practices. Eur Respir J 2010; 36: 362-369
  CrossrefPubMedGoogle Scholar
• 5 Lloyd-Owen SJ, Donaldson GC, Ambrosino N et al. Patterns of home mechanical ventilation use in Europe: results from the Eurovent survey. Eur Respir J 2005; 25: 1025-1031
  CrossrefPubMedGoogle Scholar
• 6 Srinivasan S, Doty SM, White TR et al. Frequency, causes, and outcome of home ventilator failure. Chest 1998; 114: 1363-1367
  CrossrefPubMedGoogle Scholar
• 7 Farre R, Navajas D, Prats E et al. Performance of mechanical ventilators at the patient’s home: a multicentre quality control study. Thorax 2006; 61: 400-404
  CrossrefPubMedGoogle Scholar
• 8 Holaday DA, Ma D, Papper EM. The immediate effects of respiratory depression on acid-base balance in anesthetized man. J Clin Invest 1957; 36: 1121-1129
  CrossrefPubMedGoogle Scholar
• 9 Frumin MJ, Epstein RM, Cohen G. Apneic oxygenation in man. Anesthesiology 1959; 20: 789-798
  CrossrefPubMedGoogle Scholar
• 10 Reinertsen JL. Let’s talk about error. BMJ 2000; 320: 730
  CrossrefPubMedGoogle Scholar
• 11 Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998; 280: 1000-1005
  CrossrefPubMedGoogle Scholar
• 12 Brennan TA, Leape LL, Laird NM et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370-376
  CrossrefPubMedGoogle Scholar
• 13 Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000; 320: 759-763
  CrossrefPubMedGoogle Scholar
• 14 Frey B, Kehrer B, Losa M et al. Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach. Intensive Care Med 2000; 26: 69-74
  CrossrefPubMedGoogle Scholar
• 15 Wright D, Mackenzie SJ, Buchan I et al. Critical incidents in the intensive therapy unit. Lancet 1991; 338: 676-678
  CrossrefPubMedGoogle Scholar
• 16 Bracco D, Favre JB, Bissonnette B et al. Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. Intensive Care Med 2001; 27: 137-145
  CrossrefPubMedGoogle Scholar
• 17 Capuzzo M, Nawfal I, Campi M et al. Reporting of unintended events in an intensive care unit: comparison between staff and observer. BMC Emerg Med 2005; 5: 3
  CrossrefPubMedGoogle Scholar
• 18 Welters ID, Gibson J, Mogk M et al. Major sources of critical incidents in intensive care. Crit Care 2011; 15: R232
  CrossrefPubMedGoogle Scholar
• 19 Randerath WJ, Stieglitz S, Galetke W et al. Evaluation of a system for transcutaneous long-term capnometry. Respiration 2010; 80: 139-145
  CrossrefPubMedGoogle Scholar
• 20 Gaba DM. Anaesthesiology as a model for patient safety in health care. BMJ 2000; 320: 785-788
  CrossrefPubMedGoogle Scholar