APPENDIX 1 Selection of cases subjected to critical incident analysis
Case 2. Right atrial tear at ECMO cannulation
A patient with intractable respiratory failure underwent ECMO cannulation surgery on the unit.. The
procedure was performed by a fellow in paediatric surgery supervised by an (experienced) paediatric
surgeon. After opening the jugular vein the guide wire was inserted to the depth at which arrhythmia
was seen on the monitor, then the guide wire was pulled back. The guide wire perforated the inferior
caval vein and right atrium occurred. A sternotomy was performed and the patient was resuscitated
for a long time during/after repair of the perforation. Two days after the prolonged circulatory arrest
serious hypoxic/ischemic brain damage was ascertained and treatment was discontinued.
Causal and contributing factors:
Factors
Provider factor
- The surgeon’s handling of the guide wire caused the
perforation of inferior caval vein/right atrium
Task factor
- the required depth of the guide wire insertion was not
measured before commencing the procedure, as this was not
described in a guideline or protocol
Work Environment factor
- there was no scale on the guide wire to measure the inserted
depth.
Recommendations:
Task factor
- measure optimal depth of guide wire insertion before start
procedure; this should be added to the protocol
Team factor
- talk through the procedure before start, eg use a time out
procedure to increase team situational awareness
Task factor
- use ultrasound during procedure for correct insertion and
placement of guide wires and cannulas; add to protocol
ECMO: Extra Corporeal Membrane Oxygenation
Case 3. Chest drain inserted on wrong side
A late preterm infant (GA 33 wks) was admitted on the second day of life for respiratory distress and
was mechanically ventilated. A chest x-ray performed when the respiratory distress worsened,
revelad a pneumothorax on the right side. Supervised by a neonatologist, a nurse practitioner inserted
a chest drain on the right side. Later the x-ray technician reported that on the repeat x-ray the
pneumothorax appeared to be on the left side. After inserting a drain on the left side as well, the
patients’ condition improved and the pneumothorax was successfully drained. The next day the
superfluous chest drain was removed, the day thereafter the second drain and the patient was
successfully extubated and was doing well.
Causal and contributing factors:
Factors
Work environment factor
- the correct way to insert the x-ray cassette in the film
processor is not indicated; inserting it the wrong way caused
the x-ray to be inverted
Provider factor
- the order for the x-ray after drain insertion did not specify
what side the drain was inserted; specification could have
alerted staff and technician earlier to the malposition
- left-right marks were not used when taking the x-rays; these
Task factor
had been abandoned since they kept going missing and their
use was not described in the guidelines for the x-ray
technician
- the new penlights on the unit were ineffective as a light source
Organizational factor
for transillumination of the chest; no other suitable light
sources were available
- landmarks on the x-ray (location of stomach/heart) were
Task factor
missing/inconclusive; the heart was shifted due to the
pneumothorax and the stomach was not imaged; the x-ray
field was kept small to minimize exposure to radiation both
patient and staff.
Recommendations:
Work environment factor
- adjustment of film processor to prevent insertion with wrong
side up; the equipment needs to have an indicator to force
proper insertion of the x-ray cassette
- improve information on x-ray orders; residents or consultants Provider factor
ordering x-rays need to provide all necessary details
Work environment factor
- purchase better light source for transillumination
Task factor
- use left-right marks when taking x-ray; protocol adherence
needs to be improved and left-right markers need to be made
available
Task factor
- increase the size of the x-ray field to include the stomach
when pneumothorax is to be assessed; guideline for the size of
the x-ray field needs to be adjusted
Case 4. Unexpected resuscitation
A term neonate with respiratory distress was intubated and ventilated in a general hospital and
diagnosed with esophageal atresia. The transport team collected her from the other hospital and she
was admitted to the surgical unit of the PICU. The diagnosis was confirmed and surgical repair was
planned for the next day. She was taken off the ventilator because she was doing well and appeared to
be more bothered than assisted by the endotracheal tube. During the night respiratory distress
increased again, despite multiple efforts to improve the saliva evacuation and increasing respiratory
support with nasal prongs. At the time of the nursing shift change it was decided to intubate the
patient. The paediatric intensive care fellow performed the procedure, supervised by an
anaesthiologist. The intubation was successful, but on ventilation the patient’s condition worsened
and she had to be resuscitated. Increasing abdominal distension was noted, ascribed to air being
blown into the stomach via a large tracheoesopagheal fistula. The paediatric intensivist (starting his
day-shift), the paediatric anaesthesiologist and the ENT consultant were consulted. When the patient
was stabilised she underwent a bronchoscopy and corrective surgery. The fistula was found to be the
same diameter as the trachea. She was later discharged without apparent sequelae.
Causal and contributing factors:
Factors
Provider factor
- respiratory distress at presentation should have triggered a
discussion on the need for immediate surgery; instead it was
decided to delay surgery to the next day, when the procedure
could be performed during daytime hours
Team factor
- after intubation and initiation of ventilation in the referring
hospital, the same problems with mechanical ventilation had
occurred; this information had not been passed on
Task factor
- the guideline on esophageal atresia did not clearly state to
expect ventilatory difficulties when ventilating uncorrected
atresia with a fistula
- the replogle tube for the evacuation of saliva was an unknown Work environment factor
new type of tube that had just been introduced on the PICU
and it was unclear whether it was functioning properly
- intubation was under suboptimal circumstances; the procedure Team factor
was started during the nursing handover and communication
was poor due to too many people present and unclear team
roles and responsibilities
Team factor
- situational awareness was insufficient as the risks of
intubating and ventilating a patient with a tracheo-esophageal
fistula were not recognized
- there were no guidelines on when and how a fellow should be Task factor
supervised by the paediatric intensivist
- the medical records were poor in detail on what had occurred, Provider factor
hindering the pre-operative assessment by the
anaesthesiologist and the ENT consultant
Recommendations:
- include a warning in the guideline to the effect that ventilating Task factor
patients with uncorrected esophageal atresia poses
considerable risks and recommend intubation in the operating
theatre with a bronchoscopy; the guideline needs to be
adjusted
- increase the accessibility to the guideline, eg by providing
access to the guidelines on the bedside computers
- improve the introduction and implementation of new
equipment and nursing materials
- implement the use of a time out procedure before intubation
- develop a checklist for retrieval to include all relevant data on
previous problems in the referring unit/hospital
- provide guidelines on the supervision of fellows by
intensivists: when a fellow is authorized to perform
procedures unsupervised should be made clear
- improve the quality of shift hand-overs by addressing the risks
for each patient; this should be a topic in teamtrainings
PICU: Paediatric Intensive Care Unit
ENT: Ear Nose Throat
Task factor
Work environment factor
Team factor
Task factor
Team factor
Team factor