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©2019 by European Patient Safety Foundation

WRONG TUBE-CONNECTIONS

TO THE RESPIRATOR WITH POTENTIALLY FATAL OUTCOME

Published: 20 May 2019

The European Patient Safety Foundation (EUPSF) in collaboration with the European Society of Anaesthesiology (ESA)German Society of Anaesthesiology and Intensive Care Medicine (DGAI) and the Swiss Anaesthesia Patient Safety Foundation (SPSA) launched a Safety-Alert on wrong tube-connections to the respirator.

Several cases were reported in Germany, France, Spain and other countries of severe complications with even fatal outcomes after induction of general anaesthesia, caused by wrongly connected tubes to the respirator.1, 2 In addition to that, cases of blocked tubes with fatal outcome have been reported in the UK and the corresponding recommendations published.3, 4

 

The following main errors have been reported:

  1. An accidental shortcut of respirator tubes on the level of the water-traps.

  2. The wrong connection of the manual ventilating-bag on the expiratory connector of the ventilator.

  3. Blocking of the tubings (angle-piece etc.) due to e.g. i.v.-caps.

 

General recommendations are:

  1. Proceed with technical check of every ventilator according to the manufacturer’s guidelines before it is connected to a patient.

  2. Every anaesthesiologist must confirm that the ventilator is duly functioning.

  3. Every ventilator must be equipped with a separate manual ventilating bag.

  4. „Self-check“ of most of the ventilators does not detect wrong connection of tubes, water-traps etc.

  5. Perform a short-check of the functionality of the ventilator before each induction of general anaesthesia following the checklists available here below.

REFERENCES:

  1. Prien T et al, Anästh Intensivmed 2019; 60:75–83

  2. Theissen A et al, Anaesthesia Critical Care & Pain Medicine 2019; 38:143-145

  3. Carter JA, Anaesthesia, 2004; 59:105–107

  4. Checking Anaesthetic Equipment-3. 2003. Association of Anaesthetists of Great Britain and Ireland, 21 Portland Place London.

FLYER & CHECKLISTS

To prevent these cases from happening again, the EUPSF has translated and slightly modified the corresponding checklists from the German Society of Anaesthesiology (DGAI) for the efficient management of different situations (1).  

In parallel a technical modification of these connectors is currently under debate among regulators and the industry.

SAFETY ALERT

ENGLISH

SAFETY-ALERT

VENTILATOR – CHECKLIST

SYSTEMATIC TROUBLE-SHOOTING

GERMAN

SAFETY-ALERT

GERÄTE-CHECKLISTE

SYSTEMATISCHE FEHLERSUCHE

FRENCH

ALERTE DE SÉCURITÉ

CHECKLIST DE VENTILATEUR

RÉSOLUTION SYSTÉMATIQUE DES PROBLÈMES

SPANISH

ALERTA DE SEGURIDAD

LISTADO DE VERIFICACION DEL RESPIRADOR

SOLUCIÓN SISTEMÁTICA DE PROBLEMAS

Developed in collaboration with
SENSAR

Developed in collaboration with
Anesthesia Safety Network