Mechanical ventilation | Intravascular catheters | ||||
---|---|---|---|---|---|
Incident reports triggering the intervention | No. of units | Incident reports triggering the intervention | No. of units | ||
Training/procedures | Training/procedures | ||||
Adjustment of protocols | Drop-out of HFO machine due to low pressure in combination with high amplitude | 1 | Adjustment of protocols | Faulty connection of infusion catheters, causing back stream of fluid | 1 |
Several reports on adjustments of HFO machine using the limitation button instead of the adjustment button | 2 | Blood loss after removal of an arterial catheter | 1 | ||
Several reports on incorrect position of arterial catheter transducer, causing inadequate measurement of blood pressure | 1 | ||||
Education and training on general aspects of mechanical ventilation | Non-functioning mechanical ventilation during transport | 1 | New protocol describing the use of double lumen catheters | Incorrect use of double lumen catheter (one lumen not connected and obstructed) | 1 |
Incorrect (written) orders by doctors | 3 | ||||
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 combinations | Precipitation of crystals and catheter occlusion because of high drug concentrations or incompetent drug combinations | 2 |
Checklist of set-up attached to machine | |||||
Mail to staff with manual of NO machine | |||||
‘Report of the week’ | |||||
Reminders | Reminders | ||||
Dutch names on control panel of HFO machine | Several reports on adjustments of HFO machine using the limitation button instead of the adjustment button | 1 | The use of different colours for securing of silestic catheters versus peripheral infusion catheters | Accidental removal of a silestic catheter instead of the peripheral infusion catheter | 1 |
E-mail to remind staff to use filters when administering inotropes | Several reports describing the absence of filters when administering inotropes | 1 | |||
Forcing functions | Forcing functions | ||||
The same pressure in every NO bottle | Difference in pressure between NO bottles | 1 | Highly concentrated solution of phenobarbital removed from stock | Precipitation of crystals and catheter occlusion because of incorrect drug concentrations | 1 |
Emergency power on every socket | Machines not attached to emergency power during power shutdown | 1 | |||
Other | Other | ||||
New plasters/foam material for securing of tubes | Many auto-extubations because of tubes slipping through the plaster/foam material attached to the tube | 1 | Consultation with the manufacturer of catheters for parenteral nutrition | Frequent occlusion alarms, contaminated filters, loose seams | 1 |
HFO, high-frequency oscillation; NO, nitrogen monoxide.