2002 OPEN FORUM Abstracts
EVALUATION AND PREVENTION OF INADVERTENT EXTUBATIONS: A MAJOR CONCERN FOR PATIENT CARE AND SAFETY
Misty Prater RTS, Christa Pruitt RTS, Timothy B. Op?t Holt, Ed.D., R.R.T. University of South Alabama, Mobile, Alabama
Background: Inadvertent extubations can be associated with life-threatening consequences. Therefore, evaluation and prevention of unplanned extubations are major concerns for healthcare professionals. The purpose of this study was to identify criteria for patients at high-risk of inadvertent extubation by evaluating the occurrence of and factors related to inadvertent extubation.
Methods: All mechanically ventilated patients at the University of South Alabama Medical Center (USAMC) between December 13, 2000 and January 13, 2002 were included in this study. Details of each inadvertent extubation were obtained from an incident report, chart review, and interviews with the respiratory therapists involved. Staffing, time, and location of each incident were also recorded. After reviewing the data, each unplanned extubation was placed in a category based on cause and also ranked according to severity of outcome.
Results: A total of 42 inadvertent extubations occurred (7.8 inadvertent extubations/ 1000 ventilator days). The causes of inadvertent extubations were as follows: failure to extubate or properly sedate (21%), insecure tape job (12%), inadequate sedation (19%), accidental (29%), negligence (10%), and untimely extubation (10%). The severity of outcome of the unplanned extubations were mild (n=22, 55%), moderate (n=6, 14%), and severe (n=13, 31%).
Conclusions: Our study indicates that 71% of inadvertent extubations were preventable. The majority of incidents could have been prevented with either adequate sedation or timely extubation. Education of healthcare professionals on adequate sedation, timely extubation, and patient/tube manipulation may minimize the occurrence of inadvertent extubations.