title: Oxygenation failure during cardiopulmonary bypass prompts new safety algorithm and training initiative.
abstract: Developing new strategies to improve patient safety and risk reduction is fundamental to hospital and patient success. Currently, there is a tendency in hospital safety management to focus solely on human error rather than organizational and educational causes that contribute to medical accidents. Although health care providers are the primary safety systems in medical facilities, there must be a more global, perhaps automated, approach using modern technology to prevent or reduce medical mishaps. Herein, we present an oxygenation failure with root cause analysis that prompted a new oxygenation safety algorithm and multi-service training initiative.
authors.affiliation: Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennesse 37232, USA. david.webb@Vanderbilt.Edu
authors.forename: David P
authors.initials: DP
authors.lastname: Webb
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Deegan
authors.forename: James P
authors.initials: JP
authors.lastname: Greelish
authors.forename: John G
authors.initials: JG
authors.lastname: Byrne
mesh_terms: D000465:Algorithms; D002315:Cardiopulmonary Bypass / Q000009:adverse effects* / Q000193:education*; D004868:Equipment Failure; D019544:Equipment Failure Analysis / Q000379:methods*; D004869:Equipment Safety / Q000379:methods*; D005260:Female; D006801:Humans; D007511:Ischemia / Q000209:etiology* / Q000517:prevention & control; D008875:Middle Aged; D009330:Nebulizers and Vaporizers; D010106:Oxygenators / Q000009:adverse effects*; D013663:Teaching; D013714:Tennessee