scholarly journals Equipment Failure: An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 673-677 ◽  
Author(s):  
R. K. Webb ◽  
W. J. Russell ◽  
I. Klepper ◽  
W. B. Runciman
Keyword(s):  
New Zealand ◽  
Crisis Management ◽  
Equipment Failure ◽  
Electrical Shock ◽  
Power Failure ◽  
Management Algorithm ◽  
Life Threatening ◽  
Zealand College ◽  
Incident Reports ◽  
Warming Devices

Of the first 2000 incidents reported to the Australian Incident Monitoring Study, 177 (9%) were due to “pure” equipment failure according to pre-defined criteria. Of these 107 (60%) involved anaesthetic equipment, 42 (24%) involved monitors, 17 (10%) other theatre equipment and 11 (6%) the gas or electricity supply. Ninety-seven (55% of the 177) were potentially life-threatening; of these two-thirds would be detected by the array of monitors recommended by the Australian and New Zealand College of Anaesthetists and all but 9 of the remainder would be handled by application of the crisis management algorithm recommended elsewhere in this symposium. Of the 9 remaining, 2 were electrical shock, 3 overheating of a humidifier or blood warmer, 2 the unavailability of a spare laryngoscope and 1 the consequence of a power failure. Meticulous adherence to the equipment checking and monitoring guidelines of the Australian and New Zealand College of Anaesthetists and application of a suitable crisis management algorithm should protect the patient from potentially life-threatening equipment failure in virtually all cases except electric shock, power failure and overheating of warming devices.

scholarly journals Crisis Management—Validation of an Algorithm by Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 579-592 ◽  
Author(s):  
W. B. Runciman ◽  
R. K. Webb ◽  
I. D. Klepper ◽  
R. Lee ◽  
J. A. Williamson ◽  
...  
Keyword(s):  
Crisis Management ◽  
Air Embolism ◽  
Initial Response ◽  
Anaesthetic Machine ◽  
Team Approach ◽  
Functional Diagnosis ◽  
Management Algorithm ◽  
Finite Set ◽  
Life Threatening ◽  
Working Day

Anaesthetists are called upon to manage complex life-threatening crises at a moment's notice. As there is evidence that this may require cognitive tasking beyond the information-processing capacity of the human brain, it was decided to try and develop a generic crisis management algorithm analogous to the “Phase I” immediate response routine used by airline pilots. Such an algorithm, based on the mnemonic “COVER ABCD, A SWIFT CHECK”, was developed and refined over 3 meetings, each attended by 60–100 anaesthetists and aviation psychologists. It was validated against 1301 relevant incidents among the first 2000 incidents reported to the Australian Incident Monitoring Study. It proved sufficiently robust and safe to recommend its general use as an initial response to any incident or crisis which occurs when a patient is breathing gas from an anaesthetic machine. It requires a limited knowledge base and is easily learnt and rehearsed during the anaesthetist's working day. It will provide a functional diagnosis in over 99% of cases and will correct 62% of the problems in 40–60 seconds. In the remaining 37% it will allow the anaesthetist to proceed with a “sub-algorithm”, confident in the knowledge that some important step has not been missed. In just over 30% of incidents this will be for a problem familiar to all anaesthetists (e.g. laryngospasm, bradycardia); in just over 6% it will be for a less common, more complex, but finite, set of problems (3% cardiac arrest, 1% air embolism, 1% anaphylaxis, 1% for the remaining desaturations); in less than 1% diagnosis and correction will require a more complex checklist (e.g. for malignant hyperthermia, pneumothorax). The next stage, the development of specific sub-algorithms and a structured team approach for ongoing problems, is in progress.

scholarly journals Problems with Ventilation: An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 617-620 ◽  
Author(s):  
W. J. Russell ◽  
R. K. Webb ◽  
J. H. Van Der Walt ◽  
W. B. Runciman
Keyword(s):  
New Zealand ◽  
Anaesthetic Machine ◽  
Third Party ◽  
Seal Failure ◽  
Monitoring Study ◽  
Anaesthetic Circuit ◽  
Complete Failure ◽  
Zealand College ◽  
Incident Reports ◽  
Incident Monitoring

A review of the first 2000 incidents reported to the Australian Incident Monitoring Study found 317 incidents which involved problems with ventilation. The major portion (47%) were disconnections; 61% of these were detected by a monitor. Monitor detection was by a low circuit pressure alarm in 37% but this alarm failed to warn of non-ventilation in 12 incidents (in 6 because it was not switched “on” and in 6 because of a failure to detect the disconnection). Failure of detection was usually with ventilator bellows descending in expiration. Complete failure to ventilate occurred in 143 incidents, most commonly because of a disconnection. Disconnection was associated, in one-third of the cases, with interference to the anaesthetic circuit by a third party and in nearly half with surgery on the head and neck. Leaks affected ventilation in 129 incidents, but in only 19 was ventilation totally lost; leaks associated with seal failure of the absorber were common. Misconnections occurred in 36 incidents, most commonly involving the scavenging system. The frequency of a complete failure to check an anaesthetic machine was greater when an induction room was involved than when only the operating theatre was the site of the incident. These incidents suggest that meticulous checking and monitoring for failure of ventilation, preferably using at least two separate, self-activating systems is highly desirable. The Australian and New Zealand College of Anaesthetists’ policy on low circuit pressure alarms, oximetry and capnography is vindicated by these reports.

Clinical Supervision: A Review of Underlying Concepts and Developments

2002 ◽  
Vol 36 (1) ◽  
pp. 92-98 ◽  
Author(s):  
Joanna Macdonald
Keyword(s):  
New Zealand ◽  
American Literature ◽  
Clinical Supervision ◽  
Developmental Process ◽  
Empirical Support ◽  
Personal Contact ◽  
Role Conflicts ◽  
Effective Feedback ◽  
Zealand College ◽  
The Relationship

Objective: This review examines how psychiatric clinical supervision is represented in the psychiatric literature and its relevance for Australasian psychiatry. Method: The literature was first identified then reviewed using Medline and Psychlit, manual searches of relevant journals and personal contact with some key workers in Australia and New Zealand. Results: The predominantly American literature written two to three decades ago reflected the conditions in which psychiatry was practised at that time, largely based in asylums or private offices and informed by the dominant psychoanalytic discourse of that era. These articles, frequently anecdotal and with little empirical support, conceptualized supervision as a developmental process, a syndrome, or a process of identification. They focused substantially on the nature of the relationship between the trainee and supervisor. More recent writers have included trainees’ perspectives. They have identified a number of problems with supervision, including role conflicts, uncertainty about boundaries, lack of supervisory training and lack of effective feedback, and have introduced the concepts of adult learning as highly relevant. These concerns, however, have led to little change to date. Conclusion: The implementation by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) of new training by-laws provides an opportunity to define the meaning of supervision in the current clinical context, to undertake research to clarify the key elements in the process, and to evaluate different techniques of supervision.

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