JCAHO Issues Alert Related to Ventilators

Vol. 11 •Issue 4 • Page 18
News Extra

JCAHO Issues Alert Related to Ventilators

Health care facilities have reported 23 cases of deaths or injuries related to long-term ventilation between 1995 and January 2002, according to an alert released by the Joint Commission on Accreditation of Healthcare Organizations.

Of the 23 ventilator-related cases investigated recently, 65 percent were related to the malfunction or misuse of an alarm or inadequate alarm; 52 percent were related to a tubing disconnect; and 26 percent were related to a dislodged airway tube. None of the cases was related to ventilator malfunctions.

In addition to those issues, JCAHO reported that several organizations found some ventilators didn’t always respond to tubing disconnects at all levels of the airflow circuit while only using low airway pressure alarms. For example, a disconnected airway tube could fall into a patient’s bedding, and because ventilation cycling continues, the ventilator continues to receive indications of correct air pressure.

The majority of the cases occurred in intensive care units, followed by long-term care facilities and hospital chronic ventilator units.

The information was published in JCAHO’s “Sentinel Event Alert,” a monthly newsletter that identifies specific sentinel events that have a high probability of reoccurring, their causes and steps to prevent future errors.

When physicians add technological means to a patient’s care, they not only introduce support for the patient but also new sources of risk for the patient, said Sam Giordano, executive director of the American Association of Respiratory Care, in response to the alert.

“Anytime you’re concerned about safety, you really have to add a multiplier in terms of its importance within the context of ventilator patients because they’re medically fragile — they’re the most medically fragile,” Giordano said.

The respiratory community needs to ensure the root causes outlined in JCAHO’s report are not in play in their facilities, he said. These causes include staffing, communication breakdowns and patient assessments. (See Table.)

Table. Root Causes of Ventilator-Related Deaths and Injuries
Inadequate orientation/training process 87 percent
Insufficient staffing levels 35 percent
Communication breakdown
Among staff members 70 percent
With patient/family 9 percent
Incomplete patient assessment
Room design limits observation 30 percent
Delayed or no response to alarm 22 percent
Monitor change not recognized 13 percent
Alarm off or set incorrectly 22 percent
No alarm for certain disconnects 22 percent
Alarm not audible in all areas 22 percent
No testing of alarms 13 percent
Restraint failure (escape) 13 percent
Distraction (environmental noise) 22 percent
Cultural (hierarchy/intimidation) 13 percent

In order for hospitals to prevent future ventilator-related deaths and injuries, JCAHO recommends the following actions: Review orientation and training programs for job-specific, ventilator safety-related content and include it in the competency assessment process. Review the staffing process to ensure effective staffing for ventilator patients at all times. Implement regular preventive maintenance and testing of alarm systems, and ensure that alarms are sufficiently audible with respect to distances and competing noise within the unit. Initiate interdisciplinary team training for staff caring for ventilator patients. Direct observation for ventilator-dependent patients is preferred in order to avoid over-dependence on alarms.

Preventing ventilator-related injuries is a matter of setting alarms correctly and having properly trained staff members remain near a patient in case a ventilator alarm sounds, according to Mark Siobal, RRT, director of respiratory services at San Francisco General Hospital. “People are not doing their jobs if people on life support are dying,” Siobal said. “It’s really negligence and inattentiveness to their duties. If you’re not adequately training your employees, that’s a big problem.”

Also, cost-cutting strategies in hospitals may be having a detrimental effect on respiratory patients, Giordano said. “There’s been a lot of talk in recent years from management consultant groups about dumbing jobs down, and our position is that they need to smarten jobs up,” he said. “We want our best and brightest taking care of ventilator patients because they know how to organize alarm systems and maintain the equipment. This is certainly not the only reason why respiratory therapists were invented, but it’s one of the biggest. We were created to meet a need, and that need is to manage technology within the context of respiratory care.”

Recommendations from the AARC and JCAHO’s full report can be found online at www.jcaho.org/edu_pub/sealert/sea25.html.

Debra Yemenijian and Caroline Crispino are editorial assistants of ADVANCE.