Abstract
In 2006, two cases of fatal medical accidents in which endotracheal tubes were dislodged, while nurses were repositioning the patients, occurred at National Hospital Organization (NHO) Kyushu area hospitals. In both cases, one of the major factors causing the accident was traction on the endotracheal tubes by ventilator circuits during the repositioning procedures. As a result, at two educational meetings at NHO Kyushu area hospitals it was recommended that the ventilator circuits should be temporarily disconnected before repositioning to avoid traction. Before these meetings, only five of 25 hospitals had defined manual procedures that instructed nurses to disconnect the circuits during repositioning. However, following these meetings, by 2008 21 of 24 hospitals re-wrote their manuals to instruct nurses to disconnect the circuits. A cross-sectional survey in January 2008 demonstrated that 73.9% of 3,549 patients in NHO Kyushu area hospitals were repositioned after disconnecting the circuits. In only one case, repositioning was performed by a team of a doctor and a nurse, while the remaining cases were repositioned by nursing staff only. Twenty-one hospitals, where the manual indicated that tubes were to be disconnected during repositioning, indicated that there were no problems during the performance of these procedures. These results suggest that the procedures to temporarily disconnect the circuits during repositioning can be safely performed by nursing staff alone.
