Developed to reduce flowmeter misconnections

Occasionally patients are mistakenly connected to an air flowmeter instead of oxygen with significant negative impact on the patient's condition. This has been a documented issue over many years [1]. At Flinders Medical Centre, study of incidents were monitored over a two year . Advanced Incident Management System (AIMS) reports of adverse events within FMC recorded 12 such events. Of these, intervention by the Medical Emergency Team (MET) was required eight times, and one person was admitted to ICU. Unconfirmed incidences highlight a much larger problem.

The Problem

Cluttered bedside with air flowmeter
Cluttered bedside with air flowmeter

 

  • Air and oxygen can be incorrectly connected to patients as the flowmeter connectors are the same size.
  • Reconnection to air rather than oxygen occured most frequently when a patient returned from a procedure or was transferring from another clinical unit.
  • 30% of the clinical units had at least one incorrect air /oxygen set up.
  • Black air flowmeter connectors were not readily available from the Supply Department and so staff were forced to use white (oxygen) flowmeter connectors on air supply connections.
  • Three different brands of flowmeters were in use (no standardisation).
  • Other contributing factors included: poor lighting, similar medical equipment within the immediate area & bed curtains obscuring the gas panel.
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    The Adopted Solution: Develop a device to alter the connection process

    Develop a device to alter the connection process for medical air that creates a strong visual and physical barrier.This was selected as the most viable alternative.
    • A black moulded plastic device (clearly labelled AIR) has been developed to fit over the black air flowmeter connector
    • All air outlets have been fitted with the device and a hospital wide education campaign was undertaken
    • The oxygen outlet remains unchanged and readily availabel for emergency use
    • A Patient Safety Alert was developed and promoted to medical & nursing staff.
     
    AirGuard, a visible barrier to connection, was  selected as the most viable option
    AirGuard, a visual and physical barrier to connection

    Other options investigated

    A multi-disciplinary team considered other options including 3 error proofing and 1 error reduction.

    1. Create an incompatible connector system

    The best solution, but needs to be done on a national or international scale and involves large costs and delays. Will not produce a rapid solution.

    2. Remove all air flowmeters & deliver nebulised medication with oxygen

    Not recommended by two respiratory consultants. Evidence suggests 40% of patients with COPD are CO2 retainers. Delivery of high-flow oxygen to these patients will cause hypercapnia and potentially lead to serious adverse events. 

    3. Remove all air flowmeters & supply nebulisers to all wards

    This option has many management issues that may also impact staff morale such as:
    - Sharing nebuliser pumps between patients
    - Need to locate nebuliser pump
    - Need to clean pump between patients
    - Medications due at same time, need to wait till pump finishes cycle
    - Possible shortage of power outlets at the bedside, only 2 outlets per bed
    - Patient distress or complaints as medication may be delayed.
    - Educate staff to remove all air flowmeters when not in use

    It is likley that the problem will recur; all flowmeters will not be removed if staff are busy.

    The Device

    The air flowmeter is fitted with the device, a label alerting the user that it is for air. The label is always positioned at the front of the flowmeter. The obvious labelling looks different to the oxygen outlet. A slightly different process is required to attach tubing. Fits all medical air flowmeters in use. Easy to clean, no infection risk.

    The device adds an additional connection step when attaching the circuit to an air flowmeter. One hand is used to flip the AirGuard out of the way, while the other makes the connection to the spigot. Two-handed operation increases the likelihood the user will focus on the task and review their actions.

    The Results

    These devices were distributed throughout the hospital in July 2007 & the system has been under evaluation since. There have been no incidents reported to AIMS since the devices were installed throughout Flinders Medical Centre. No issues with the use of the device have been found according to a staff feedback survey. Trials are currently under way at the Berri and Repatriation General Hospitals in South Australia, and with Misericordia Community Hospital, Edmonton, Alberta.

    Where to next?

    Potentially the device could be fitted to all non-oxygen flowmeters and made in appropriate colours to meet international standards. Colours of the plastic parts and labeling can be easily changed.

    For further information or sales enquiries regarding the AirGuard go to FBE Pty Ltd .

    References [1]

    Biomedical Safety & Standards July 15 1991, Patient receives air instead of oxygen
    The Wall Street Journal June 27 2007, Tackling Tube Misconnection
    Sentinal Event Alert issue 21 Jul 1 2001, Medical gas mixup
    Government of South Australia, Clinical Governance Patient safety alert, Wrong gas delivery to patients
    Patient Safety Advisory, Veterans Health Administration Warning System VA central Office, Mar 5 2002 Confusion between Oxygen and Compressed Air wall outlet
    ECRI Guidance Article, Preventing misconnections of lines and cables

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