HSIB report on CPAP devices during COVID-19

This HSIB investigation looked into the safety risk of treating patients with coronavirus (COVID-19) with Continuous Positive Airway Pressure Ventilation (CPAP) outside of critical care units. The investigation was launched after HSIB became aware of a patient with COVID-19 requiring CPA, who was found on the floor of a side room having called for assistance. The CPAP tubing had become disconnected from the mask meaning the patient’s breathing was not supported. Sadly, the patient died.

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