Ventilators are used to provide vital oxygen to patients who may not be able to breathe on their own. When used properly, they can save a life. When used improperly, they can cause brain damage or death.
Hypoxic brain injuries occur when a brain is deprived of oxygen. Virtually all hypoxic brain injuries and deaths from mechanical ventilators are preventable; yet, every year patients are injured or killed when these devices fail to work properly or are misused by caregivers. Information below provided by Perspectives in Nursing.
Staffing issues contribute to the majority of ventilator injury/death cases. Caregivers who lack training and orientation with regard to ventilator operation may be unfamiliar with the machine and unable to recognize when a patient may need more ventilator support. Inadequate training can also potentially lead to barotrauma and ventilator-induced injury through the use of excessive pressures and/or volumes.
The second most common factor contributing to ventilator injury and/or death is communication breakdown – usually among staff members, such as respiratory therapists and nurses. For example, if a proper shift report is not given, then valuable information might be omitted.
Incomplete Patient Assessment
Poor room design that limits observation of patients can lead to incomplete patient assessment. Another hindrance is the placement of a patient into the prone position. When a patient is in the prone position, adequate securing of the endotracheal tube becomes much more important and difficult (in the prone position, gravity can cause the tube to slip out.) Also, there is an increased chance of the tube becoming kinked underneath the patient, which can hinder and may even prevent tidal volume delivery.
Equipment issues include alarms that are turned off or set incorrectly, no alarm, alarms that aren’t audible in all areas, alarms not tested for functionality prior to being placed on the patient, and restraint failure leading to unplanned extubation. All of these scenarios can have disastrous consequences for the patient.
Another factor contributing to ventilator injury and/or death is caregiver distraction due to environmental noise, two main sources of which are loud machinery and false alarms. A common cause of a false alarm is a coughing patient or one who has a high respiratory rate and is in need of sedation. A common response is to repeatedly silence the alarms or reset them to a wider range.
If you or a loved one have been injured because of a doctor’s or hospital’s mistake, contact Thomas J. Henry immediately. We are available 24/7, nights and weekends.