title: Root-cause analysis of an airway filter occlusion: a way to improve the reliability of the respiratory circuit.
abstract: 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.
  
  
  METHODS
  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.
authors.affiliation: Anaesthesiology Division and Quality of Care Unit, Geneva University Hospitals, Rue Micheli-du-Crest 24, CH-1211 Geneva 14, Switzerland.
authors.forename: P
authors.initials: P
authors.lastname: Garnerin
authors.forename: E
authors.initials: E
authors.lastname: Schiffer
authors.forename: E
authors.initials: E
authors.lastname: Van Gessel
authors.forename: F
authors.initials: F
authors.lastname: Clergue
mesh_terms: D000293:Adolescent; D015984:Causality; D004868:Equipment Failure; D004869:Equipment Safety; D005374:Filtration / Q000295:instrumentation*; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D008297:Male; D012121:Respiration, Artificial / Q000295:instrumentation*; D017751:Safety Management / Q000379:methods*; D013647:Task Performance and Analysis