SAFETY AND EFFICACY OF A VENTILATOR DATABASE INTERFACE

This report describes a ventilator dysfunction that arose during the m echanical ventilation of a lung transplant recipient. The problem was discovered because the data on the computer-based information manageme nt system (CIMS) was different from that on the ventilator's dials. Th is incident is important because of the continued extensive use of ana log mechanical ventilators, the increasing popularity of CIMS, and the patient safety implications of the incident.