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A Critical Event in the CT Room

A Critical Event in the CT Room. Peter Campos, CEO Dr Alphonse Roex, EDMS The Queen Elizabeth Hospital and Health Service Health Round Table Townsville 12 -14 June 2002. Case. 80 yr old, critically ill, ICU patient Apache 2 algorithm 92% Intubated, ventilated, renal failure

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A Critical Event in the CT Room

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  1. A Critical Event in the CT Room Peter Campos, CEO Dr Alphonse Roex, EDMS The Queen Elizabeth Hospital and Health Service Health Round Table Townsville 12 -14 June 2002

  2. Case • 80 yr old, critically ill, ICU patient • Apache 2 algorithm 92% • Intubated, ventilated, renal failure • CT scan abdomen requested • Patient from ICU to CT room • Registered Nurse, Resident, Orderly

  3. Portable equipment • Ventilator, oxygen cylinder • Hand ventilation apparatus • Intravenous stand • IV fluids and syringe pumps • 3 channel monitor • oxygen saturation, heart rate, blood pressure

  4. CT room • Patient + equipment lifted and positioned on CT barouche; difficult transfer • Reconnecting to oxygen to wall outlet • Repositioning O2 probe and arterial line • Chest was rising, vital signs OK

  5. Incident • ± 1 minute later RN: “patient is cyanotic” • Resident: “ the ventilator is off”! • RN flicked the on-off button • Cardiac arrest: resuscitation

  6. Incident • Patient returned to ICU • Died the next day • Case reported to the Coroner • Ventilator failure?

  7. Critical Event Analysis • Find facts and reconstruct events • What? How? Why? • Report with recommendations • Debrief and support staff • Encourage open disclosure

  8. “The ventilator was off” Unknown mechanism • Equipment failure? • Switch changed in position during transfer? • Inadvertently switched off? • ?

  9. Portable ventilator • Mains power and battery power • Toggle switches for power and type of ventilation • Alarm if high airway pressure, apnoea or disconnection: • audible alarm (when switched on) • visual alarm: display panel lights up

  10. Display screen Portable ventilator: • Mains power: backlit with a yellow light • Battery power: black on green/grey background • Only to light up when alarming ICU ventilators: • Bright light for both functions and alarm • Dark when in an off position

  11. Conclusion • Interpretation error; no equipment failure • Display screen is dark “ventilator is off” • Immediate resuscitation: adequate clinical response • Primary cardiac arrest in a critically ill patient after transport from ICU to CT room • Critical event analysis: important learning tool

  12. General recommendations Critical event analysis Include as well: • staff debrief • open disclosure

  13. Specific recommendations • Instruct staff as to display lighting on portable ventilator • Inform manufacturer about the interpretation error; standardisation • Ensure direct clinical observation of patient • Attach a hinged hard plastic gate over the two toggle switches

  14. Critical Event Analysis

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