Anaesthesia and intensive care
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. Problems with ventilation: an analysis of 2000 incident reports.
A review of the first 2000 incidents reported to the Australian Incident Monitoring Study found 317 incidents which involved problems with ventilation. The major portion (47%) were disconnections; 61% of these were detected by a monitor. Monitor detection was by a low circuit pressure alarm in 37% but this alarm failed to warn of non-ventilation in 12 incidents (in 6 because it was not switched "on" and in 6 because of a failure to detect the disconnection). ⋯ The frequency of a complete failure to check an anaesthetic machine was greater when an induction room was involved than when only the operating theatre was the site of the incident. These incidents suggest that meticulous checking and monitoring for failure of ventilation, preferably using at least two separate, self-activating systems is highly desirable. The Australian and New Zealand College of Anaesthetists' policy on low circuit pressure alarms, oximetry and capnography is vindicated by these reports.
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. Air embolism--an analysis of 2000 incident reports.
There were 19 cases of air embolism (1%) among the first 2000 incidents reported to the Australian Incident Monitoring Study. No embolism-induced fatalities were reported. Serious acute systemic effects occurred in 14 incidents; one circulatory arrest required electrical counter-shock. ⋯ Doppler monitoring was not reported in this series. A successful first response for management included head-down posture, manual ventilation, 100% oxygen and control of the air entry site. Cerebral arterial gas embolism may induce vascular endothelial damage and possible delayed neurological sequelae; hyperbaric oxygen therapy should be considered.
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. Human failure: an analysis of 2000 incident reports.
Information of relevance to human failure was extracted from the first 2,000 incidents reported to the Australian Incident Monitoring Study (AIMS). All reports were searched for human factors amongst the "factors contributing," "factors minimising", and "suggested corrective strategies" categories, and these were classified according to the type of human error with which they were associated. ⋯ Failure to check equipment or the patient contributed to nearly one-quarter of all incidents, and inadequate crisis management contributed to a further 1 in 8. "Skill-based errors" (slips and lapses) were directly responsible for 1 in 10 of all incidents, and were thought to make an indirect contribution in up to one quarter. "Technical errors" were responsible for about 1 in 8 incidents. Analysing the relative contribution of each type of error for each type of problem allows the development of rational preventative strategies.(ABSTRACT TRUNCATED AT 250 WORDS)
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. The oxygen analyser: applications and limitations--an analysis of 200 incident reports.
The first 2000 incidents reported to the Australian INcident Monitoring Study were analysed with respect to the role of the oxygen analyser; 27 (1%) were first detected by the oxygen analyser. All of these were amongst the 1256 incidents which occurred in association with general anaesthesia, of which 48% were "human detected" and 52% "monitor detected". The oxygen analyser was ranked 7th and detected 4% of these monitor detected incidents. ⋯ In a theoretical analysis of these 1256 incidents it was considered that the oxygen analyser, used on its own, would have detected 114 (9%), had they been allowed to evolve (3% before any potential for organ damage). In 4 incidents an oxygen analyser gave faulty readings, in 3 caused a leak and in one a total circuit obstruction; 5 incidents were not detected because the alarm had been disabled. Despite the advent of piped gas supplies, failure of gas delivery or delivery of a "wrong" gas mixture still occurs surprisingly frequently in current anaesthetic practice; hypoxic mixtures were supplied on 16 occasions, other "wrong" mixtures on 23 and the oxygen supply failed on 7 occasions.(ABSTRACT TRUNCATED AT 250 WORDS)
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. The capnograph: applications and limitations--an analysis of 2000 incident reports.
The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to the role of the capnograph. One hundred and fifty-seven (8%) were first detected by a capnograph and there were a further 18 (1%) in which capnography was contributory. Of the 1256 incidents which occurred in association with general anaesthesia 48% were "human detected" and 52% "monitor detected". ⋯ There were 20 reports of "failure", over two-thirds of which would not have occurred with appropriate checking and calibration. Seven were due to gas sampling problems and 6 to apnoea alarm failure. Two circuit leaks and 2 faulty unidirectional valves were not detected; on 3 occasions problems occurred due to power failure, calibration problems, or misinterpretation of an alarm.(ABSTRACT TRUNCATED AT 250 WORDS)