The Science Journal of the American Association for Respiratory Care

2007 OPEN FORUM Abstracts

DEVELOPMENT OF A TAXONOMY FOR PREVENTABLE MECHANICAL VENTILATOR ERRORS

K. W. Wright1, P. Evans2, M. E. Anders3

Background: Preventable medical errors are a leading cause of death in the U.S. In 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert summarizing the results of a root cause analysis of 23 ventilator-related deaths in the USA. JCAHO’s findings underscore the problem of human error, and emphasize the need for hospitals and other healthcare facilities to implement a rigorous program of staff training and ventilator maintenance. Thus, we developed a simple taxonomy of mechanical ventilator errors. Ultimately, this taxonomy will be used to create an orientation program for ventilator troubleshooting.

Method: We conducted a retrospective review of biomedical engineering service requests related to mechanical ventilators, and then developed a taxonomy of errors. An explanation letter and survey was sent to nine area health care facilities in Arkansas, Louisiana, and Texas requesting data for total number of beds, ICU beds, full time therapists and service requests for each ventilator in present use by the facility. Service requests from January 1, 2003 to September 31, 2006, identified specific ventilator-related problems associated with biomedical service calls. Information from the service requests were sorted and classified according to type, preventability of error, and potential of user correction prior to generating a biomedical service call.

Results: A total of 549 service requests from nine biomedical departments provided data and service requests. From this review, four primary categories for error classification were developed: Setup, Power, Patient Circuit and Setting. Of these, 145; or 26 percent, were deemed “preventable” and classified in their respective category.

Conclusions: The development of a taxonomy for the classification of mechanical ventilator errors is an important initial step toward the prevention of errors. This taxonomy will be useful in classifying errors, and understanding the training needs of respiratory therapists. Reduction in ventilator error will benefit patients, as well as decrease time and costs associated with reprocessing equipment, use of disposables, unnecessary repairs, and possible litigation.

Summary of Preventable Error Results
Number of Participating Hospitals Total Number of Ventilators Total Service Requests Total user correctable Service Requests Total Percent Correctable (Average) Errors Involving Setup Issues Errors Involving Power Issues Errors Involving Pt. Circuit Issues Errors Involving Settings Issues
9 189 549 145 26% 68 12 36 29



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