This Signal is about the availability and reliability of airway suction equipment. A sample incident reads:
“Patient vomited brown liquid. She could not breathe and fell to the floor. I shouted for the resus trolley. The suction on the arrest trolley was disassembled. In my haste to re - assemble this, I did it incorrectly and the suction did not work.”
Suction is a basic requirement for airway management and often an essential intervention in the care of the critically ill patient. Suction equipment that is not ready for immediate use delays commencement of effective cardiopulmonary resuscitation and increases the risk of aspiration and death.
The National Patient Safety Agency (NPSA) has received 104 reports of serious incidents describing problems with airway suction systems between January 2005 and December 2009. The majority of incidents occurred during an emergency situation and the equipment was needed urgently to clear the patient’s airway. In seven reports the failure to suction is likely to have contributed to the patient’s death.
The incidents describe equipment that was:
• unavailable (e.g. no suction device on the resuscitation trolley or none on the ward);
• set up incompletely (e.g. without suction bags or tubes);
• set up incorrectly (e.g. tube directly connected to the wall-mounted unit);
• not cleaned (e.g. filter and jars full of fluid);
• not working on battery (unit not fully charged).
The reports suggest that lack of training and poor checking procedures were underlying causes for these incidents.
Organisations may wish to consider:
• Regular training for all users (i.e. assembling, checking and using the equipment).
• Implementing agreed arrangements for ensuring that suction equipment is always readily available. To support effective checking of the equipment, specific criteria could be added to the daily checklist (e.g. necessary items are available and clean, suction manometer reading shows sufficient pressure, power supply is connected where appropriate).
• Standardising suction devices. The variety of devices used within a hospital is an additional contributing factor and standardisation is a key step to minimise the risks.
Please contact us with your initiatives to reduce risk in this area.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.