Skip Navigation

This Article
Right arrow Full Text
Right arrow Full Text (PDF)
Right arrow E-Letters: Submit a response to the article
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (1)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Garnerin, P.
Right arrow Articles by Clergue, F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Garnerin, P.
Right arrow Articles by Clergue, F.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

British Journal of Anaesthesia, 2002, Vol. 89, No. 4 633-635
© 2002 The Board of Management and Trustees of the British Journal of Anaesthesia

Short Communications

Root-cause analysis of an airway filter occlusion: a way to improve the reliability of the respiratory circuit

P. Garnerin*,1,2, E. Schiffer1, E. Van Gessel1 and F. Clergue1

1 Anaesthesiology Division and 2 Quality of Care Unit, Geneva University Hospitals, Rue Micheli-du-Crest 24, CH-1211 Geneva 14, Switzerland*Corresponding author

Background. To show how root-cause analysis can identify system-level factors causing critical incidents and accidents, we present an investigation of the occlusion of an airway filter during anaesthesia.

Method. The investigation was based on a framework specifically developed for the analysis of medical accidents. This framework helped to identify the chronology and outcome of the case, the care management problems and the factors that led to the event. Information was obtained by interviewing the anaesthesiologist in charge of the patient.

Results. Occlusion was not recognized because the filter was hidden under the drapes and below the patient’s head. To reduce the frequency of this event, we recommend that filters should be visible, placed above the level of the patient’s body, or mounted on the expiratory circuit, at a distance from patient’s airway.

Conclusions. To allow appropriate corrective actions, critical incidents and accidents should be systematically investigated using root-cause analysis.

Br J Anaesth 2002; 89: 633–5


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?




Disclaimer: Please note that abstracts for content published before 1996 were created through digital scanning and may therefore not exactly replicate the text of the original print issues. All efforts have been made to ensure accuracy, but the Publisher will not be held responsible for any remaining inaccuracies. If you require any further clarification, please contact our Customer Services Department.