Interruption of circuit set up and priming due to time constraints (trying to finish ahead of anaesthesia in order to leave the room due to COVID airways protocol). Normal cue to add monitoring device disposable into circuit lost (added after circuit finished). Checklist item too non-specific - "arteral CDI calibrated".
CDI was assumed to be in circuit and functional throughout case - calibrated with each gas. Error only noticed after warm gas with low pO2 of 7.8kPa despite a CDI value of 27. FIO2 increase resolved the arterial saturation drop that was noticed on anaesthetic monitor.
No injuries were noted to have occurred to the patient.
Terumo CDI Sensor
- The checklist has been changed from "CDI calibrated" which was deemed to be a poor cue to ensure it was connected to the circuit, to CDI connected to circuit.
- It was reported to other members of the team to highlight the potential of its omission -some had made a similar mistake previously.
- The department is looking at a way of improving in-house problem solving and reporting after this incident. The department are currently using apps on mobile devices where if anything challenges the normal work flow it can be logged via phone in a word or two in a matter of seconds. This allows for increased visibility for all and for the safety team to follow up any events.
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