title: Ventilator-disconnect and death: a case study and a safety device.
abstract: Deaths and injuries related to accidental ventilator disconnection occur in complex ways. A death related to accidental ventilator disconnection is presented from a subacute ventilator facility, and corrective action is discussed. Single-limb ventilators are now equipped with a flow-bypass coupling that prevents patient-side occlusion during disconnect and therefore prevents low-pressure alarm malfunction. Physicians and respiratory therapists can consider this device to prevent partial or total occlusion of the ventilator tracheostomy adapter, thus allowing a low-pressure alarm in the event of a disconnect.
authors.affiliation: Pulmonary/Subacute Service, Alameda Hospital, 2070 Clinton Avenue, Alameda, CA 94501, USA. slowery@pol.net
authors.forename: William S
authors.initials: WS
authors.lastname: Lowery
mesh_terms: D000368:Aged; D056902:Clinical Alarms; D004867:Equipment Design; D004868:Equipment Failure; D017809:Fatal Outcome; D006801:Humans; D008297:Male; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy; D012121:Respiration, Artificial / Q000295:instrumentation; D012122:Ventilators, Mechanical / Q000592:standards*