ANALYSIS OF a critical incident involving a
patient with acute hypercapnic respiratory failure
(AHRF) is provided in this article. The analysis
discusses the misuse of oxygen therapy during an
emergency admission, the lack of understanding
of chronic obstructive pulmonary disease (COPD)
and AHRF, and appropriate use of non-invasive
ventilation. Recommendations are provided to
enable healthcare professionals to identify patients
at risk of AHRF and modify their practice to help
reduce the number of such critical incidents.
Proposed by the Department of Health (DH)
(1998), clinical governance was introduced as part
of quality reforms to the NHS. Within the clinical
governance framework (DH 1999), healthcare
organisations are accountable for improving the
quality of service provision and safeguarding high
standards of care. Critical incident reporting was
recommended within this framework as a way to
improve the quality of health care by identifying,
investigating and alleviating poor clinical
performance (Brocklehurst and Walshe 1999).