Table 2 Risk management mitigations
From: Causes of adverse events in home mechanical ventilation: a nursing perspective
Cause | Consequence | Target group: measures for risk mitigation |
|---|---|---|
Mobilisation & Transfer | Failure of ventilation | Care competence: Carers trained to improve fixation of tube Care competence: Carers trained to recognise signs of medical problems |
Airway Obstruction | Failure of ventilation | Device competence: Knowledge about alarm types (high pressure) Manufacturers: Making alarms understandable Medical competence: Blood saturation measurement Care competence: Suction |
Tracheostomy decannulation | Failure of ventilation | Device competence: Knowledge about alarm type (low pressure) Equipment competence: Secure attachment connection Manufacturers: Mechanisms to avoid tube dragging |
Tube Change Interval | Contamination/infection | Nursing service operator: Replacement tube available Manufacturers: Harmonise change intervals of the tubing material and store them in the device |
Power Failure | Device blackout | Device competence: Alarm type (power alarm) Nursing service operator: Device backup Nursing service operator: Battery backup Ambu bag Emergency contact numbers |
Medical Problem/Health Deterioration | Acute health deterioration | Environmental conditions: Emergency contact numbers Environmental conditions: Helping system (advice) Medical competence: Trained to detect early signs of health problems (e.g. silent infection) |
General | Â | Emergency training: Training concepts for emergency management Nursing service operator: Escalation/support concept |
Nursing service operator: Process analysis of the setting and resources at home | ||
Nursing service operator: Checklist for care process |