A veterinary practice unintentionally used carbogen, a mixture of 95% oxygen and 5%
carbon dioxide, as an anaesthetic carrier gas over a 5 month period. The error went
unnoticed until the practice obtained a multiparameter monitor with capnography. Fractional
concentration of inspired carbon dioxide was persistently elevated in all animals
despite new non-rebreathing systems with fully functional one-way valves being used,
adequate fresh gas flow rates and active soda lime in the circle systems. A registered
veterinary nurse (RVN) eventually discovered the source of the problem and was able
to rectify the mistake.
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References
- Technical Information Sheet 21: Medical Gases. BGCA policy on valve outlets.2019 (ISSN 2398-9386)https://bcga.co.uk/wp-content/uploads/2021/09/BCGA-TIS-21-Revision-2-May-2019.pdfDate accessed: October 12, 2022
- We need to talk about error: Causes and types of error in veterinary practice.Vet Rec. 2015; 177 (438–438)
- Human error: Models and management.BMJ. 2000; 320: 768-770
- Patient safety: Latent risk factors.Br J Anaesth. 2010; 105: 52-59
- Teams, tribes, and patient safety: Overcoming barriers to effective teamwork in healthcare.Postgrad Med J. 2014; 9: 149-154
Article info
Publication history
Published online: December 28, 2022
Accepted:
December 20,
2022
Received:
October 26,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2022 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.
