Table 3

Interventions made in units following incident reports associated with mechanical ventilation or intravascular lines

Mechanical ventilationIntravascular catheters
Incident reports triggering the interventionNo. of unitsIncident reports triggering the interventionNo. of units
 Adjustment of protocolsDrop-out of HFO machine due to low pressure in combination with high amplitude1 Adjustment of protocolsFaulty connection of infusion catheters, causing back stream of fluid1
Several reports on adjustments of HFO machine using the limitation button instead of the adjustment button2Blood loss after removal of an arterial catheter1
Several reports on incorrect position of arterial catheter transducer, causing inadequate measurement of blood pressure1
 Education and training on general aspects of mechanical ventilationNon-functioning mechanical ventilation during transport1 New protocol describing the use of double lumen cathetersIncorrect use of double lumen catheter (one lumen not connected and obstructed)1
Incorrect (written) orders by doctors3
 Double-check of machine set-ups (by second person)Faulty set-up of machine (HFO, NO circuit, connecting tubes, compressed air, humidification)5 Adjustment of drug concentrations and drug combinationsPrecipitation of crystals and catheter occlusion because of high drug concentrations or incompetent drug combinations2
 Checklist of set-up attached to machine
 Mail to staff with manual of NO machine
 ‘Report of the week’
 Dutch names on control panel of HFO machineSeveral reports on adjustments of HFO machine using the limitation button instead of the adjustment button1 The use of different colours for securing of silestic catheters versus peripheral infusion cathetersAccidental removal of a silestic catheter instead of the peripheral infusion catheter1
 E-mail to remind staff to use filters when administering inotropesSeveral reports describing the absence of filters when administering inotropes1
Forcing functionsForcing functions
 The same pressure in every NO bottleDifference in pressure between NO bottles1 Highly concentrated solution of phenobarbital removed from stockPrecipitation of crystals and catheter occlusion because of incorrect drug concentrations1
 Emergency power on every socketMachines not attached to emergency power during power shutdown1
 New plasters/foam material for securing of tubesMany auto-extubations because of tubes slipping through the plaster/foam material attached to the tube1 Consultation with the manufacturer of catheters for parenteral nutritionFrequent occlusion alarms, contaminated filters, loose seams1
  • HFO, high-frequency oscillation; NO, nitrogen monoxide.