Summary
Case study looking at how a Covid patient on a ventilator deteriorated due to their heat and moisture exchanger filter (HMEF) being flooded with secretions. The identified incident highlighted a possible under-recognised patient safety risk of the need to replace such filters.
NHS England: Sudden patient deterioration due to secretions blocking heat and moisture exchanger filters
https://www.england.nhs.uk/patient-safety/using-patient-safety-events-data-to-keep-patients-safe/how-we-acted-on-patient-safety-issues-you-recorded/sudden-patient-deterioration-due-to-secretions-blocking-heat-and-moisture-exchanger-filters/
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