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Functionally crossed pipelines. An intermittent condition by a faulty ventilator.
W M Weightman1, V Fenton-May, R Saunders
1Department of Anaesthetics, University Hospital of Wales, Cardiff.
Anaesthesia
|June 1, 1992
Summary
Ventilators can malfunction, creating dangerous high blood oxygen levels in intensive care patients. This study identifies a rare fault where ventilators connect oxygen and air pipelines, recommending pipeline monitoring to prevent future incidents.
Area of Science:
- Medical Engineering
- Intensive Care Medicine
- Patient Safety
Background:
- High blood oxygen tension (hyperoxemia) in intensive care units (ICUs) can cause patient harm.
- The source of unexpectedly high oxygen levels in ICU patients is often unclear.
Purpose of the Study:
- To identify the cause of unexpectedly high blood oxygen tension in intensive care patients.
- To investigate a specific type of ventilator malfunction as a potential cause.
- To recommend preventative measures.
Main Methods:
- Analysis of patient data over a 5-year period.
- Investigation of a normally functioning ventilator acting as a conduit between gas pipelines.
- Survey of Quality Control Pharmacists in England and Wales regarding similar incidents.
Main Results:
- A specific ventilator fault was identified as the cause of high blood oxygen tension.
- This fault involves the ventilator intermittently connecting oxygen and air pipelines.
- Evidence suggests this fault has occurred at least five times in the past 10 years.
Conclusions:
- Ventilator malfunction is a critical factor in unexpected hyperoxemia.
- Intermittent connection between gas pipelines poses a significant patient safety risk.
- Monitoring of medical gas pipeline composition is recommended for prevention.