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Causes of adverse events in home mechanical ventilation: a nursing perspective

BACKGROUND: Adverse events (AE) are ubiquitous in home mechanical ventilation (HMV) and can jeopardise patient safety. One particular source of error is human interaction with life-sustaining medical devices, such as the ventilator. The objective is to understand these errors and to be able to take...

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Autores principales: Lipprandt, Myriam, Liedtke, Wenke, Langanke, Martin, Klausen, Andrea, Baumgarten, Nicole, Röhrig, Rainer
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9513291/
https://www.ncbi.nlm.nih.gov/pubmed/36167541
http://dx.doi.org/10.1186/s12912-022-01038-2
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author Lipprandt, Myriam
Liedtke, Wenke
Langanke, Martin
Klausen, Andrea
Baumgarten, Nicole
Röhrig, Rainer
author_facet Lipprandt, Myriam
Liedtke, Wenke
Langanke, Martin
Klausen, Andrea
Baumgarten, Nicole
Röhrig, Rainer
author_sort Lipprandt, Myriam
collection PubMed
description BACKGROUND: Adverse events (AE) are ubiquitous in home mechanical ventilation (HMV) and can jeopardise patient safety. One particular source of error is human interaction with life-sustaining medical devices, such as the ventilator. The objective is to understand these errors and to be able to take appropriate action. With a systematic analysis of the hazards associated with HMV and their causes, measures can be taken to prevent damage to patient health. METHODS: A systematic adverse events analysis process was conducted to identify the causes of AE in intensive home care. The analysis process consisted of three steps. 1) An input phase consisting of an expert interview and a questionnaire. 2) Analysis and categorisation of the data into a root-cause diagram to help identify the causes of AE. 3) Derivation of risk mitigation measures to help avoid AE. RESULTS: The nursing staff reported that patient transportation, suction and tracheostomy decannulation were the main factors that cause AE. They would welcome support measures such as checklists for care activities and a reminder function, for e.g. tube changes. Risk mitigation measures are given for many of the causes listed in the root-cause diagram. These include measures such as device and care competence, as well as improvements to be made by the equipment providers and manufacturers. The first step in addressing AE is transparency and an open approach to errors and near misses. A systematic error analysis can prevent patient harm through a preventive approach. CONCLUSION: Risks in HMV were identified based on a qualitative approach. The collected data was systematically mapped onto a root-cause diagram. Using the root-cause diagram, some of the causes were analysed for risk mitigation. For manufacturers, caregivers and care services requirements for intervention offers the possibility to create a checklist for particularly risky care activities.
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spelling pubmed-95132912022-09-27 Causes of adverse events in home mechanical ventilation: a nursing perspective Lipprandt, Myriam Liedtke, Wenke Langanke, Martin Klausen, Andrea Baumgarten, Nicole Röhrig, Rainer BMC Nurs Research Article BACKGROUND: Adverse events (AE) are ubiquitous in home mechanical ventilation (HMV) and can jeopardise patient safety. One particular source of error is human interaction with life-sustaining medical devices, such as the ventilator. The objective is to understand these errors and to be able to take appropriate action. With a systematic analysis of the hazards associated with HMV and their causes, measures can be taken to prevent damage to patient health. METHODS: A systematic adverse events analysis process was conducted to identify the causes of AE in intensive home care. The analysis process consisted of three steps. 1) An input phase consisting of an expert interview and a questionnaire. 2) Analysis and categorisation of the data into a root-cause diagram to help identify the causes of AE. 3) Derivation of risk mitigation measures to help avoid AE. RESULTS: The nursing staff reported that patient transportation, suction and tracheostomy decannulation were the main factors that cause AE. They would welcome support measures such as checklists for care activities and a reminder function, for e.g. tube changes. Risk mitigation measures are given for many of the causes listed in the root-cause diagram. These include measures such as device and care competence, as well as improvements to be made by the equipment providers and manufacturers. The first step in addressing AE is transparency and an open approach to errors and near misses. A systematic error analysis can prevent patient harm through a preventive approach. CONCLUSION: Risks in HMV were identified based on a qualitative approach. The collected data was systematically mapped onto a root-cause diagram. Using the root-cause diagram, some of the causes were analysed for risk mitigation. For manufacturers, caregivers and care services requirements for intervention offers the possibility to create a checklist for particularly risky care activities. BioMed Central 2022-09-27 /pmc/articles/PMC9513291/ /pubmed/36167541 http://dx.doi.org/10.1186/s12912-022-01038-2 Text en © The Author(s) 2022 https://creativecommons.org/licenses/by/4.0/Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ (https://creativecommons.org/publicdomain/zero/1.0/) ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
spellingShingle Research Article
Lipprandt, Myriam
Liedtke, Wenke
Langanke, Martin
Klausen, Andrea
Baumgarten, Nicole
Röhrig, Rainer
Causes of adverse events in home mechanical ventilation: a nursing perspective
title Causes of adverse events in home mechanical ventilation: a nursing perspective
title_full Causes of adverse events in home mechanical ventilation: a nursing perspective
title_fullStr Causes of adverse events in home mechanical ventilation: a nursing perspective
title_full_unstemmed Causes of adverse events in home mechanical ventilation: a nursing perspective
title_short Causes of adverse events in home mechanical ventilation: a nursing perspective
title_sort causes of adverse events in home mechanical ventilation: a nursing perspective
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9513291/
https://www.ncbi.nlm.nih.gov/pubmed/36167541
http://dx.doi.org/10.1186/s12912-022-01038-2
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