Deaths, injuries often come from multiple failures

Ventilator-related deaths and injuries often are caused by multiple system failures, especially in the intensive care unit (ICU), according to a recent report from the Joint Commission on Accreditation of Healthcare Organizations.

As of January 2002, the Joint Commission had reviewed 23 sentinel events that involved deaths or injuries related to long-term ventilation. Nineteen resulted in death and four in coma. Of the 23 cases, the Joint Commission says 65% were related to the malfunction or misuse of an alarm or an inadequate alarm; 52% were related to a tubing disconnect; and 26% were related to a dislodged airway tube.

"A small percentage of the cases were related to an incorrect tubing connection or wrong ventilator setting," the Joint Commission reports. "None of the cases were related to ventilator malfunctions. As the percentages indicate, ventilator-related deaths and injuries are often related to multiple failures that lead to negative outcomes. The majority of the cases occurred in hospital ICUs, followed by long-term care facilities and hospital chronic ventilator units."

When the root causes were analyzed, 87% of the incidents involved inadequate orientation or training processes and 35% included insufficient staffing levels. Seventy percent of the cases involved a communication breakdown among staff members; 30% were related to improper room design that limited the observation of the patient; and staff did not respond immediately to ventilator alarms in 22%.

"In addition, several organizations found that during the use of low airway pressure alarms only, some ventilators did not always respond to tubing disconnects at all levels of the airflow circuit," the report states. "For example, the disconnected airway tube may fall into the bedding or against the patient’s body, ventilation cycling continues, and the ventilator continues to receive indications of correct air pressure."

The Joint Commission advises risk managers to ensure that their organizations adhere to guidelines from the Food and Drug Administration and the American Association of Respiratory Care (AARC) for testing and evaluating ventilators. The AARC Clinical Practice Guideline for patient ventilator systems recommends that:

• Professionals responsible for application, adjustment, and monitoring of ventilators, alarm systems and airways, possess relevant education, and have undergone validated competency testing.

• Systems are in place to check ventilator and monitoring system performance before and during clinical use.

• All devices and systems are maintained according to manufacturers’ specification. This includes medical gas systems.

• A tracking system is in place to identify, analyze, and remedy all ventilator-related incidents that lead to serious injury or death.

• Protocols for the application and discontinuance of mechanical ventilation are in place.

• A mechanism is in place to track outcomes of all ventilator patients.

• Organized, periodic, ventilator-related continuing education is accessible to those professionals responsible for the many components of care directed to ventilator patients.

In addition, the Joint Commission makes these recommendations:

• Review orientation and training programs for job-specific, ventilator safety-related content and include in competency assessment process.

• Review staffing process to ensure effective staffing for ventilator patients at all times.

• Implement regular preventive maintenance and testing of alarm systems.

• Ensure that alarms are sufficiently audible with respect to distances and competing noise within the unit.

• Initiate interdisciplinary team training for staff caring for ventilator patients.

• Direct observation of ventilator-dependent patients is preferred in order to avoid overdependence on alarms.