The Critical Care Department, The Queen Elizabeth Hospital, Gayton Road, King's Lynn, UK; The Lister Hospital, Coreys Mill Lane, Stevenage, UK.
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.
J Crit Care. 2018 Oct;47:159-163. doi: 10.1016/j.jcrc.2018.06.024. Epub 2018 Jun 30.
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.
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.
Only 30% (6/20) recognised and undertook corrective measures.
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.
无意中同时使用热湿交换器（HME）和加热加湿器（HH）可能导致过滤器积水和通风管突然堵塞，从而产生致命后果。在收到英格兰国民保健署（NHS England）的安全警报、我们机构发生一起接近事故和教育提醒后，我们引入了新的指南，即在重症监护病房仅使用 HH，仅在患者转科时使用 HME。此后再未发生此类事件，但该解决方案可能存在缺陷。两年后，我们评估了员工的知识水平，以及在发生这种错误时识别该错误的可能性。
在一项模拟研究中，对一名经气管插管和通气的模拟人使用了同时含有 HME 和 HH 的呼吸回路。参与者被要求评估该回路，识别错误并采取纠正措施。
仅有 30%（20 人中的 6 人）识别并采取了纠正措施。
尽管进行了教育和系统变更，但对该错误的识别仍不理想。系统变更可能会降低错误发生的可能性，但发生错误时，可能无法识别。通过设备内的安全工程故障安全装置，可以显著减少或消除此错误，该装置可以提醒工作人员提高识别能力并防止犯错。
