Mismanagement of Ventilated Patients

Service: Risk Management
Subject: Care

Mechanical ventilators are sophisticated medical devices requiring training to ensure positive outcomes and reduce associated harm. Long-term ventilated patients can be successfully managed in complex care, chronic rehabilitation or community (home) settings. Management of ventilated patients for the long-term requires care providers (regulated and unregulated) as well as the patient and/or family can safely modify the settings (where appropriate), set (where allowed) and respond to critical alarm and communicate any clinical status changes and equipment-related challenges to the most responsible practitioner or case coordinator.

Common Claim Themes

System issues

  • Inappropriate assignment of care providers for patients with health conditions that are complex, unpredictable, unstable or if the patient is at high risk for negative outcomes.

Equipment

  • Equipment failure (e.g., faulty alarms)

Team and practitioner

  • Ignoring or silencing ventilator alarms and alerts without investigation of cause (normalizing alarms and alerts).
  • Repositioning of patient that leads to kinked or disconnected ventilator tubing or accessories.
  • Failure to reassess the ventilated patient and the ventilator connections and settings when moving the patient from one position to another.
  • Inability to replace decannulated tracheostomy.
  • Failure to identify and/or respond to deteriorating respiratory status.
  • Inadequate monitoring and assessments of ventilated patients.

Documentation and communication

  • Inadequate documentation, including (but not limited to) delayed reporting, and inconsistent documentation of normal findings and routine interventions.

Case Study

During an assisted turning the ventilator alarm was activated. The provider silenced the alarm twice within a short interval of time. Subsequently, the provider noticed the patient was experiencing respiratory distress. The provider reattached the ventilator tubing not realizing the diaphragm in the tubing had fallen out. As a result the patient did not receive the necessary oxygen and experienced a cardiac arrest. Expert review was not supportive of care noting the staff may not have appreciated the seriousness of a ventilator alarm and lacked the knowledge and skills necessary to respond to such a ventilator-related incident.

Mitigation Strategies

Reliable Care Processes

  • Adopt a current evidence based algorithm and/or criteria to facilitate the safe and optimal transition of ventilator-dependent patient from hospital to home that includes (but is not limited to):
    • Patient and family (where applicable) willingness and capacity to manage the risks associated with home mechanical ventilation;
    • Availability of trained formal and informal care providers to provide ventilator care, including respite and backup care providers;
    • Assistive devices and mobility needs; 
    • Home environmental factors (e.g., adequate number of grounded electrical outlets and back-up source of electricity);
    • Notifying the power company to receive notification of planned power outages (physician letter may be required); 
    • Development of a formal and agreed to contingency plan for power outages, accidental disconnection, equipment failure and other urgent and emergent situations occurring in the home, work, transit or school (as applicable);
    • Notifying the equipment supplier of the patient’s needs and required equipment (e.g., backup ventilator) .
  • Adopt a standardized evidence based protocol, decision aid and/or clinical care pathway for the care and support of ventilated patients in the home care setting.
  • Implement formal and multifaceted strategies to ensure all regulated and unregulated care providers caring for and monitoring ventilated patients have the appropriate knowledge and experience to safely do so, including (but not limited to):
    • Understanding of the patient’s normal respiratory and behaviour patterns
    • Triggers for reporting changes to the most responsible practitioner and/or care coordinator; 
    • Mechanical ventilators (e.g., ventilator function, ventilator settings, features and troubleshooting);
    • Tracheostomy care;
    • Airway suctioning; 
    • Manual bagging and ventilation support;
    • Oxygenation;
    • Emergency procedures;
    • Infection prevention and control practices;
    • Inspection and preventive maintenance for equipment (e.g., tank oxygen, suctioning unit, ambu-bag, backup tracheostomy cannulas);
    • Trouble shooting ventilators and alarms (e.g., high or low pressure signal, ventilator disconnect).
  • Ensure care providers receive copies or have immediate access to required information or  documentation including (but not limited to):
    • The patient’s ventilator guidelines and/or instructions from the discharging facility or most responsible physician;
    • User guidelines and/or protocols based on the manufacturer’s recommendations for ventilator preventive maintenance and servicing requirements;
    • The emergency plan for ventilator failure and unanticipated patient deterioration.

Equipment

  • Clarify and communicate the accountability for performing regular checks on equipment and backup supplies (e.g., tank oxygen, suctioning unit, ambu-bag, backup tracheostomy cannulas).

Patient and Family-Centred Care

  • Advocate for care conferences with the patient and healthcare providers. 
  • Implement formal multifaceted and targeted safety strategies to support and enhance patients and families knowledge of:
    • Mechanical ventilators (e.g., ventilator function, ventilator settings, features and troubleshooting);
    • Tracheostomy care;
    • Airway suctioning; 
    • Manual baging;
    • Emergency planning and executing response procedures;
    • Equipment maintenance and cleaning;
    • Trouble shooting.

Documentation and Communication

Strategies specific to regulated and unregulated care providers

  • Ensure complete and timely documentation of:

    • Initial ventilator settings (baseline) as well as changes to ventilator parameters; 
    • Equipment routines (e.g., changes, cleaning, fluid top-ups etc.);
    • The airway status (e.g., tracheostomy is secure and positioned);
    • Airway care maneuvers (including suctioning) when performed;
    • Tolerance of suctioning including the nature of secretions suctioned (e.g., amount, colour, consistency);
    • The patient’s respiratory status, including pulse oximetry readings (if available) as ordered.
  • Ensure complete and timely documentation of patient and/or family education (what was discussed, demonstrated, teach back, risks, steps to take during an emergency, etc.).

Monitoring and Measuring

  • Implement formal strategies to monitor and measure  the effectiveness and efficiency of, and interdisciplinary team adherence to ventilator-related policies, decision aids and clinical pathways, including  (but not limited to):
    • Adoption of formal quality measures and indicators;
    • Sharing of learnings from ventilator-related incidents involving fetal health surveillance (FHS) with the interdisciplinary team (e.g., learnings from chart audits, trigger tools, on-call respiratory therapy logs,  patient and family complaints, incident reports, team debriefs, critical incident and quality of care reviews, medical legal claims, coroner reports and related recommendations);
    • Encouraging patients and family to report incidents.

References

  • Boroughs D, Dougherty JA., (2012). Decreasing accidental mortality of ventilator-dependent children at home: a call to action. Home Healthc Nurse. 30(2): 103-11.
  • Critical Care Services Ontario. (2013). Long-Term Mechanical Ventilation: Toolkit for Adult Acute Care Providers.
  • Hill GJ, Adams BD. (2010). Accidental oxygen disconnection in the emergency department. J Emerg Trauma Shock. 3(2): 185-186.
  • Pham JC, Williams T, Sparnon EM. (2016). Ventilator-related adverse events: A taxonomy and findings from 3 incident reporting systems. 
  • Thomas AN, Galvin I. (2008). Patient safety incidents associated with equipment in critical care: A review of reports to the UK National Patient Safety Agency. Anaesthesia. 63: 1193-1197.
  • Yang, L, Nonoyama M, Pizzuti R, et al. (2016). Home mechanical ventilation: A retrospective review of safety incidents using the World Health Organization International Patient Safety Event classification. Can J Respir Ther. 53(3): 85-91.