Safety and efficacy of a ventilator database interface

This report describes a ventilator dysfunction that arose during the mechanical ventilation of a lung transplant recipient. The problem was discovered because the data on the computer-based information management system (CIMS) was different from that on the ventilator's dials. This incident is important because of the continued extensive use of analog mechanical ventilators, the increasing popularity of CIMS, and the patient safety implications of the incident.