Cause of Device-Related Incident
*Not stated

Clinical Specialty or Hospital Department
CCU / ICU / NICU; Pulmonary / Respiratory Therapy

Device Factors
*Not stated

Document Type

External Factors
*Not stated

Mechanism of Injury or Death
Failure to deliver therapy; Suffocation

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated

Stand-Alone Low-Pressure (Disconnect) Alarms Can Be Fooled: Proper Setup Is Essential


  • Line-powered units should have a power-failure alarm. Battery-powered units should have a low-battery indicator. Check that all batteries are sufficiently charged.
  • To help prevent moisture entry into the alarm unit during operation, place the unit approximately 30 cm above the pressure-sensing site and watch for moisture buildup in the sensing line during ventilation.
  • Connect the pressure-sensing line at the patient circuit connection to the artificial airway.
  • Use an alarm unit that allows selection of a pressure-alarm point just below the peak inspiratory pressure (e.g., 5 to 10 cm H20).
  • With the alarm time delay set to zero, disconnect the patient circuit at the artificial airway and confirm that an alarm occurs.
  • Never leave mechanically ventilated patients unattended in critical care settings.


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