Causes of adverse events in home mechanical ventilation: a nursing perspective
Open accessAbstract
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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Patients need comprehensive information on living with home mechanical ventilation, tailored to their needs, especially about adverse events.
“Indeed, they need to receive comprehensive information on living with HMV, tailored to their needs [14–16], especially about adverse events [17].”
From Life Experiences in Neuromuscular Tracheotomized Patients in Times of Covid-19 (2023) · cites this paper as [17]
Citation [17] is attached specifically to the claim that patients need information about adverse events. The Discussion (page unavailable) calls for transparency about adverse events to help nursing staff respond, and discusses education for organisations and nursing schools. Searches for patient education and informing patients about adverse events found no passage recommending that patients receive such information. (LLM, conf=0.72)
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- Authors
- Lipprandt, M., Liedtke, W., Langanke, M., Klausen, A., Baumgarten, N., & Röhrig, R.
- Affiliations
- RWTH Aachen University (DE)
- Protestant University of Applied Sciences Rhineland-Westphalia-Lippe (DE)
- Carl von Ossietzky Universität Oldenburg (DE)
- University of Sheffield (GB)
- Corresponding author
- Lipprandt, Myriam
- Venue
- BMC Nursing
- Published
- 2022-09-27
- Volume
- 21
- Issue
- 1
- Pages
- 264-264
- ISSN
- 1472-6955 (ISSN-L)
- PMC
- PMC9513291
- OpenAlex
- W4297370924
- Cited by
- 5
- References
- 31
- Citations by year
- 2026: 4 · 2023: 1
- FWCI
- 0.29
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Nursing (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- RWTH Publications (RWTH Aachen) (submittedVersion, cc-by)
- Funders
- RWTH Aachen University
- Topics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Surgery › Healthcare Technology and Patient Monitoring
- Health Sciences › Health Professions › Medical Laboratory Technology › Quality and Safety in Healthcare
- Keywords
- home mechanical ventilation, adverse events, patient safety, nursing care, root cause analysis, risk mitigation, patient transport, suctioning, decannulation, checklists, near misses
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