Sir,
A rare iatrogenic problem was observed due to lack of knowledge of resuscitation bag and absence of safety system. In our tertiary care hospital, as a part of emergency department, we keep a regular check of emergency equipment in all the general wards. Any error in the life-saving equipment, missing or expired drugs if found are replaced immediately and nursing staffs are educated accordingly. Surprisingly, while inspecting in a general ward, the team could find an unusual arrangements of the resuscitation bag [Figure 1]. The patient end was connected to the resuscitation bag in such a way that the lip valve is facing in opposite direction. In this arrangement after compressing the resuscitation bag, the volume of gas was expelled out due to unidirectional valve. Thus, the patient could have not been ventilated with such an arrangement and may lead to fatal complications. If it was used on a patient who is having spontaneous or in gasping state, the breaths assisted with such bag would have not delivered to the patient, as there is no channel for the entry of either room air or supplied oxygen. During expiration (shown as dashed lines), the expired air reaches unidirectional lip valve which may open and enters the ventilation bag.
Figure 1.
The movement of air/oxygen (Solid lines) and expired air (Dashed lines)
On enquiring, the nursing staff informed that it was dismantled for cleaning purpose as directed by the manufacturer but assembled the parts wrongly. According to the manufacturer, after cleaning process and reassembling the parts, pre-use check is mandatory before it is used on the patient. However, the nursing staff failed to do so due to lack of knowledge. The working principle of the resuscitation bag and cleaning process along with pre-use check according to manufacturer's recommendation were taught to entire staff nurses.
The Diameter Index Safety System (DISS) could have successfully prevented such a dangerous assembly of the resuscitation bag. It has been successfully proved in anesthesia gas supply and anesthesia delivery systems.[1,2] Thus, we recommended that DISS should be introduced to the resuscitation bags to avoid such deadly arrangements.
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Conflicts of interest
There are no conflicts of interest.
References
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