Acute hypercapnic respiratory failure: application of a novel human factors approach to improve recognition and management

摘要

Cases of AHRF were reviewed as safety critical incidents using ahuman factors approach. Outputs from the case reviews were usedto develop a bow-tie model; identifying barriers which facilitateeffective management and threats to barriers which compromisepatient care. Multidisciplinary workshops were undertaken todiscuss how these safety critical barriers could be strengthenedand from this the following interventions derived: an automatedalert for AHRF, simulation training for doctors and advance carepractitioners, management checklists and a referral script, increaseduse of capillary blood gases and oxygen saturation wristbands. Data was collected before and after the intervention byretrospective case note review of patients with AHRF (pH 6.5) on blood gas analysis.