Avoiding Patient Injury During Mechanical Ventilation: Slips, Lapses and Knowledge-Based Errors

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Myles Warner
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1 Avoiding Patient Injury During Mechanical Ventilation: Slips, Lapses and Knowledge-Based Errors John Salyer RRT, BS, MBA, FAARC Senior Clinical Systems Analyst Seattle Children s Hospital

2 Since We Are Talking About Ventilators

3 May You Live in Interesting Times

4 May You Live in Interesting Times

9 Murphy s Law 2005: Barrels labeled as instrument cleaning detergent were incorrectly filled with used hydraulic fluid and delivered to hospitals. One hospital did not catch the mistake surgical cases were done with instruments that were in-part, cleaned with used hydraulic fluid

10 The RT Cheese Hole Model Individual Local Organizational Distraction Fatigue Slips Lapses Risk taking Training/Competency Policies Equipment/Supplies Inadequate Supervision Knowledge Based Errors Design of Processes Staffing Supplies & Equip Culture of Safety Collaboration Active Errors: Latent Errors/Conditions:

11 Let Not Your Heart Be Troubled A dark journey Remember the Orchestra Conductor Remember, most errors are systemically induced

12 Switched insp and exp limbs Using advanced settings without adequate training Pencil Checks in Cruise Control Confusing nomenclature Peds vs adult modes Absolute versus indexed volumes Not plugging vent in Tidal volume inaccuracy Not validating circuit compliance Flow starvation Insensitive trigger settings Humidifier dry- turned off- in wrong mode- gradient set wrong Excessive fluid condensation in exp limb Occluded HME Failure to take vent out of stand-by Lamentations Expiratory filter occlusion Suction saline port left open Suction catheter left inserted Suctioning more than necessary Suction pressure too high Alarms not set properly Volutrauma-overdistention Atelectrauma-PEEP-disconnections Not having manual resuscitator at bedside, no mask, wrong sized mask. In-line med distal to bacterial filter/hme Inaccurate weight used for indexing Failure to turn vent on after trach care Accidental extubations/trach dislodgements Heliox mishaps

13 No No Not the Nitrogen Infant receiving sub-ambient O 2 therapy, e.g. N 2 bleed into circuit as a bridge to cardiac surgery Taken from the ICU to O.R. by RN-MD Manually ventilated with flow inflating bag Pt became bradycardic in elevator Discovered that the (only) cylinder of gas brought along was N 2

14 Inadvertent Room Air Resuscitation of an infant after prolonged labor and delivery. Apgars: 1minute = 5, 5 minutes = 1 Aggressive resuscitation, no response Repeated checks of the manual resuscitator revealed: O 2 flow-meter turned on Reservoir bag inflating UA line placed for fluid resuscitation First PaO 2 was 8 mmhg Patient was getting F I O 2 = 0.21

15 One Reason I Don t Like Flow Inflating Bags (there are many others) Ventilated PICU BPD pt, frequent desaturation episodes During one of these episodes two RN s bagged the patient with flow inflating bag They had trouble hearing breaths sounds, and they could not visually detect chest rise They pulled the ETT RT arrives in room, discovers the pressure manometer line on the resuscitator was disconnected It took nine attempts to reintubate and the patient did not recover

16 Why I Hate Jury Rigging Pt on HFNC Inspiratory limb of HFNC circuit was substituted with the inspiratory limb of a neonatal ventilator circuit. Same color, same size, same fitting, equipped with heated wire. Pt became inconsolate Nasal blanching noticed Circuit felt very warm to the touch A tragic ending

17 Human factors in pediatric anesthesia incidents. Paediatr Anaesth Mar;16(3): Pediatric anesthesia group 28,600 cases during study full time anesthesiologists 2 year study Analyzed all self reported errors 688 incidents reported (2.4%) of all cases Of these 42% (284) involved human factors

18 Active Types of Errors Active & Latent Point of the sword Actual mistakes, lapses, slips, violations Latent Previously existing conditions that promoted or allowed errors to occur.

19 Error Classification Scheme

20 Error Management

21 Number of Incidents Reported by Each Anesthetist During Study Period Error Management

Critical Care Medicine 2005; 33:1694 1700 Prospective 1-year observational study.

22 Critical Care Medicine 2005; 33: Prospective 1-year observational study. Two 10 bed ICU s at Brigham and Women s Hospital Incidents were collected with use of a multifaceted approach including direct continuous observation. Two physicians independently assessed incident type, severity, and preventability as well as systems-related and individual performance failures.

23 A total of 391 patients with 420 unit admissions were studied during 1490 patient-days. Found 120 adverse events in 79 patients (20.2%), 55% non-preventable 45% preventable adverse events The rates per 1000 patient-days for Rate/ Life 1000 d Threatening all adverse events % preventable adverse events 36.2 serious errors %

25 Investigation of an Organizational Accident Dangers Hazards Defenses Losses Latent Condition Pathways Unsafe Acts Causes Investigation Local Workplace Factors Organizational Factors

26 Preventable Ventilator Deaths Staffing Inadequate orientation/training 87% Insufficient staffing levels 35 % Communication breakdown Between Staff Members 70 % With patient/family 9 % Incomplete patient assessment Room design limits observation 30 % Delayed or no response to alarm 22 % Monitor change not recognized 13 %

27 Slips Switched insp and exp limbs Accidental extubation Esophageal intubation Insensitive trigger settings Confusing nomenclature Peds vs adult modes Absolute versus indexed volumes

28 Violations Using advanced settings without adequate training Failure to monitor with E T CO 2

29 Lapse Suction saline port left open Suction catheter left inserted Excessive suction pressure Alarms not set properly Failure to take out of stand-by Insensitive trigger settings Dry humidifier Humidifier turned off Humidifier in wrong mode Humidifier gradient set wrong Excessive fluid accumulation

30 Excessive Condensate Tracheal pressure waveforms during CPAP are shown for condensate volumes of 0, 5, 10, 15, & 20 ml cmh 2 O and a flow rate of 8 L/min. Pressure signals were sampled at 1,024 khz for 8 s. Youngquist TM, et al. Respiratory Care 2013: in Press

31 Rob s Refrigerator

32 Knowledge Based Error Suctioning more than necessary Volutrauma-overdistention Atelectrauma-PEEP-disconnections Tidal volume inaccuracy Flow starvation

33 Tidal Volume Inaccuracy PRVC High % 258% % -113% PRVC Low % 268% % -127% TCPL High % 255% % -83% TCPL Low % 157% % -180% VC High % 213% % -108% VC Low % 261% % -101% Error = (Displayed-Actual)/Actual)

34 Exhaled Volume (ml) Neonatal Volume Accuracy Volume-limited (VC) High Preliminary Results Baby Log Evita XL Servo i Avea PB 840 VC Plus PB Observed Vt- Vent Display Pneumotach (Cosmo)

Pressure Smessure The Risk of Overdistention Ventilated rats Four groups control-low pressure, low volume PIP = 7 cm H 2 O, Vt = 13 + 3 ml/kg high pressure-high volume cranked up the pressure- PIP =

37 Pressure Smessure The Risk of Overdistention Ventilated rats Four groups control-low pressure, low volume PIP = 7 cm H 2 O, Vt = ml/kg high pressure-high volume cranked up the pressure- PIP = 45 cm H 2 O, Vt = ml/kg high pressure-low volume thoraco-abdominal banding (literally), 45 cm H 2 O, Vt = ml/kg low pressure-high volume itsy-bitsy, teeny-tiny, little rat iron lung Vt = ml/kg

38 Dreyfuss Results Extravascular Lung Water Content Bloodless Dry Lung Weight Albumin Space

39 Volumtrauma 3 kinds of ventilator induced lung injury Mechanical-overdistention Biochemical Mechanical-underdistention From JAMA 2012

40 Normal Alveolus Inflamed Alveolus

41 Ventilator Induced Lung Injury Capillary Leak Fu Z, JAP 1992; 73:123

42 Avoiding Volutrauma JAMA. 2012;308(16): studies and > 1400 participants.

43 Using Lower Tidal Volumes Effect on Lung Injury

44 Using Lower Tidal Volumes Effect on Mortality

45 Using Lower Tidal Volumes Effect on Pulmonary Infection and Atelectasis

46 Rob Doing Research

47 Atelectrauma Let s go to the film

48 Countermeasures Search for Latent Errors Clear policy environment Create a perception of risk Create a set of agreed upon principles for drawing the line between acceptable and unacceptable actions. Considering: Intent. Actions. Consequences.

49 Decision Tree for Determining Culpability of Unsafe Acts Actions intended? yes Consequences intended? yes Sabotage, malevolent damage, etc. no no Sub. abuse, no mit. Unauthorized substance? no yes Medical condition? yes Sub. Abuse w/ mit. no yes Possible reckless violation Knowingly violate safety rule? yes Procedures available, workable, correct? no System induced violation no Pass substitution test? Possible negligent error no Deficiency in training, equipment? no Diminishing Culpability yes yes System induced error History of unsafe acts? yes no Blameless error/ needs f/u Blameless error

50 Countermeasures Standardization Equipment- Visual Job Aides Processes-Measures Training Training Training Drills Double Checks Focus

51 Learning disabilities are tragic in children, but they are fatal in organizations. -- Peter Senge

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