Causes for Adverse Events in Home Ventilation: A Nursing Perspective

Abstract Background: Adverse events are ubiquitous in home ventilation and can jeopardise patient safety. Especially the interaction with life-sustaining medical devices such as the ventilator is a source of potential errors. The goal is to know the errors to be able to react adequately to them. With a systematic analysis of hazards and their causes, measures can be taken to prevent damage to patients.Methods: A systematic adverse event analysing process was conducted to identify the causes for adverse events (AE) in intensive home care. The process consisted of three analysis steps. 1) an input phase consisting of an expert interview, and a questionnaire. 2.) an analysing process into a cause-effect diagram that can lead to cause of adverse events and 3.) risk mitigation measures have been derived to avoid adverse events. Results: The nursing staff indicated transport of the patient and suction, de-cannulation as the most causal factors for adverse events. They would like to have support in the form of checklists for care activities and a reminder function for e.g. tube changes. In the cause-effect diagram, many causes are listed that are addressed in risk mitigation. Here, concrete measures such as devices and care competence but also improvements by the providers and manufacturers are demanded. The first step in dealing with adverse events is transparency and an open approach to errors and near misses. A systematic error analysis can prevent patient harm through a preventive approach.