Vikesh Patel1, Maryanne Z A Mariyaselvam2, Catherine Peutherer3, Peter J Young4. 1. The Critical Care Department, The Queen Elizabeth Hospital, Gayton Road, King's Lynn, UK; The Lister Hospital, Coreys Mill Lane, Stevenage, UK. Electronic address: vikesh.patel@hotmail.co.uk. 2. The Critical Care Department, The Queen Elizabeth Hospital, Gayton Road, King's Lynn, UK; Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0SP, UK. Electronic address: m.mariyaselvam@nhs.net. 3. The Critical Care Department, The Queen Elizabeth Hospital, Gayton Road, King's Lynn, UK; Bedford Hospital, Kempston Road, Bedford, UK. 4. The Critical Care Department, The Queen Elizabeth Hospital, Gayton Road, King's Lynn, UK.
Abstract
PURPOSE: The inadvertent, simultaneous use of heat and moisture exchangers (HMEs) and heated humidifiers (HHs) can result in waterlogging of the filter and sudden ventilation tube occlusion, with potentially fatal consequences. Following an NHS England Safety Alert, a near miss and educational reminders in our institution, we introduced new guidelines to solely use HHs in the intensive care unit and HMEs only for patient transfers. No further incidents have occurred, however this solution is potentially fallible. Two years later, we sought to assess staff knowledge and likelihood of recognising this error should it occur. MATERIALS AND METHODS: In a simulation study, a tracheally intubated and ventilated mannequin had a breathing circuit containing both a HME and a HH. Participants were asked to assess the circuit, identify errors and undertake corrective measures. RESULTS: Only 30% (6/20) recognised and undertook corrective measures. CONCLUSIONS: Despite educational efforts and system changes, recognition of this error remained poor. System changes may reduce the likelihood of the error occurring, but when it does, recognition may not occur. Substantial reductions or elimination of this error may be achieved through a safety-engineered fail-safe within the equipment, which alerts staff to improve recognition and prevent the mistake.
PURPOSE: The inadvertent, simultaneous use of heat and moisture exchangers (HMEs) and heated humidifiers (HHs) can result in waterlogging of the filter and sudden ventilation tube occlusion, with potentially fatal consequences. Following an NHS England Safety Alert, a near miss and educational reminders in our institution, we introduced new guidelines to solely use HHs in the intensive care unit and HMEs only for patient transfers. No further incidents have occurred, however this solution is potentially fallible. Two years later, we sought to assess staff knowledge and likelihood of recognising this error should it occur. MATERIALS AND METHODS: In a simulation study, a tracheally intubated and ventilated mannequin had a breathing circuit containing both a HME and a HH. Participants were asked to assess the circuit, identify errors and undertake corrective measures. RESULTS: Only 30% (6/20) recognised and undertook corrective measures. CONCLUSIONS: Despite educational efforts and system changes, recognition of this error remained poor. System changes may reduce the likelihood of the error occurring, but when it does, recognition may not occur. Substantial reductions or elimination of this error may be achieved through a safety-engineered fail-safe within the equipment, which alerts staff to improve recognition and prevent the mistake.