Anaesthesia and intensive care
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. Problems related to the endotracheal tube: an analysis of 2000 incident reports.
The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to problems with the endotracheal tube; 189 (9%) were reported. The most common problem was endobronchial intubation which accounted for 42% of these 189 reports; endobronchial intubation was the most common cause of arterial desaturation in the 2000 incidents. Obstructions and oesophageal intubation each accounted for 18% of the 189 problems with tubes. ⋯ The pulse oximeter and capnograph first detected 58% of these incidents; a further 25% were detected clinically. The pulse oximeter is the "front-line" monitor for endobronchial intubation, and the capnograph the "front-line" monitor for oesophageal intubation, disconnection and obstruction. Recommendations are made for how to prevent problems and how to determine the nature of those that do occur.
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. Blood pressure monitoring--applications and limitations: an analysis of 2000 incident reports.
Of the first 2000 incidents reported to the Australian Incident Monitoring Study, 1256 occurred in relation to general anaesthesia and 81 of the latter were first detected by blood pressure (BP) monitoring. A further 25 incidents not associated with general anaesthesia were first detected by blood pressure monitoring, giving a total of 106. In the monitor detection of incidents in relation to general anaesthesia, BP monitoring ranked fourth after oximetry, capnography and low pressure alarms. ⋯ The 10 cases of invasive monitoring failure were predominantly due to mains power loss, hardware breakage or operator error. In a theoretical analysis of the 1256 GA incidents, it was considered that on its own, BP monitoring would have detected 919 (73%), but in the vast majority, by the time this detection has occurred, potential organ damage could not be excluded. It is recommended that BP be measured at regular intervals dictated by clinical requirements (usually at least every five minutes).(ABSTRACT TRUNCATED AT 250 WORDS)
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Anaesth Intensive Care · Oct 1993
The Australian Incident Monitoring Study. The "wrong drug" problem in anaesthesia: an analysis of 2000 incident reports.
Amongst the first 2000 incidents reported to the Australian Incident Monitoring Study, there were 144 incidents in which the "wrong drug" was nearly or actually administered to a patient. Thirty-three percent of the incidents involved ampoules and just over 40% syringes; in over half of the latter the syringes were of the same size, and also, in over half, they were correctly labelled. In 81% of the 144 incidents the "wrong drug" was actually given. ⋯ Factors which contributed significantly to the incidents were similar appearance, inattention and haste. "Failure of communication" was a significant factor in syringe incidents when two or more staff were involved. The only significant factor which minimised the outcome was rechecking of the syringe or drug ampoule before giving the drug. Strategies suggested to address the "wrong drug" problem include education of staff about the nature of the problem and the mechanisms involved; colour coding of selected drug classes for both ampoules and syringes; the use of standardised drug storage, layout and selection protocols; having a drawing up and labelling convention; and the use of checking protocols.
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Anaesth Intensive Care · Oct 1993
Biography Historical ArticleThe Weller-Ash nitrous oxide apparatus.