The Australian Incident Monitoring Study. The oxygen analyser: applications and limitations--an analysis of 200 incident reports.
The first 2000 incidents reported to the Australian INcident Monitoring Study were analysed with respect to the role of the oxygen analyser; 27 (1%) were first detected by the oxygen analyser. All of these were amongst the 1256 incidents which occurred in association with general anaesthesia, of which 48% were "human detected" and 52% "monitor detected". The oxygen analyser was ranked 7th and detected 4% of these monitor detected incidents. This figure would have been much higher had the oxygen analyser been correctly used on more occasions. The oxygen analyser detected 10 ventilator-driving-gas leaks into the circuit, 6 hypoxic mixtures due to rotameter settings, 3 inappropriate nitrous oxide concentrations, 2 disconnections and 1 leak at the common gas outlet, and 2 partial and 1 total failure of ventilation. In a theoretical analysis of these 1256 incidents it was considered that the oxygen analyser, used on its own, would have detected 114 (9%), had they been allowed to evolve (3% before any potential for organ damage). In 4 incidents an oxygen analyser gave faulty readings, in 3 caused a leak and in one a total circuit obstruction; 5 incidents were not detected because the alarm had been disabled. Despite the advent of piped gas supplies, failure of gas delivery or delivery of a "wrong" gas mixture still occurs surprisingly frequently in current anaesthetic practice; hypoxic mixtures were supplied on 16 occasions, other "wrong" mixtures on 23 and the oxygen supply failed on 7 occasions.(ABSTRACT TRUNCATED AT 250 WORDS)
Barker
L
L
Department of Anaesthesia and Intensive Care, University of Adelaide, S.A.
Webb
R K
RK
Runciman
W B
WB
Van der Walt
J H
JH
D000059:Accidents / Q000706:statistics & numerical data*; D000758:Anesthesia / Q000009:adverse effects*; D001315:Australia / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008991:Monitoring, Physiologic / Q000379:methods*; D010100:Oxygen / Q000032:analysis*; D012121:Respiration, Artificial / Q000295:instrumentation*; D012308:Risk Management / Q000379:methods*
D010100:Oxygen