Unrecognized Failure of Oxygen Delivery to Patients. · 32 patients had a least one ‘reportable event’ of unrecognised failure of oxygen delivery. Prevalence of 6.3% (95% CI 4.52-8.79)

Unrecognized Failure of

Oxygen Delivery to Patients.

Dr Matthew Matusik (MBBS

FANZCA)

Disclosures.

▪Honoured.

Disclosures.

▪Honoured.

▪ Inventor, Owner and Legal Manufacturer of

SureflO2™ (Oxygen mask with integrated flow

indicator).

Disclosures.

▪Honoured.



indicator).

▪Primary mission purpose: Proving that there is a

safety problem with current oxygen systems.

Disclosures.

▪Honoured.



indicator).





• 1. The sentinel event.

• 2. Is there really problem?

• 3. Why is there a problem?

• 4. Risk mitigation?







Failure of Oxygen Delivery.

1. The sentinel event.













*AIRWAY

&

*OXYGEN





AIRWAY ?

OXYGEN ?





AIRWAY – Adequate

OXYGEN ?



AIRWAY – Adequate

OXYGEN – YES


























▪QUESTION: ”Is there a safety problem

current oxygen systems”?




▪ANSWER: ”Depends on who you ask.”


1. Literature.

▪“We would like to bring to your attention a potential safety issue regarding

oxygen delivery to patients during transport using a dial regulator.

The oxygen dial regulator was apparently set to deliver a flow of 5 l/min from

cylinder to face mask. The transparent oxygen mask was seen to be forming a

mist on its wall, corresponding to the patient's chest excursions. She was

transferred on her bed from the theatre to the recovery area within 2–3 min,

where her oxygen saturation was found to have decreased to 76%.”

▪“The oxygen source was changed to the recovery room wall supply and the

saturation rose within seconds to 99%.”

▪“On closer inspection of the oxygen delivery system, the oxygen cylinder was

half full, the dial regulator was set just short of the 6 l/min mark and no oxygen

flow was detected at the outlet of the dial regulator.”

▪“This incident raises issues surrounding the quality of design of the

equipment in question and users awareness of its limitation. The incident

demonstrated that a lack of understanding of how the equipment functions,

rendered the equipment unsafe.”

Oxygen delivery failure. First published online: 22 JUN

2011. Anaesthesia. Volume 58, Issue 2, pages 190–191,

http://onlinelibrary.wiley.com/doi/10.1111/ana.2003.58.issue-2/issuetoc


2. Perioperative Nurses.

▪”Happens quite a bit.”

-Anaesthetic and Recovery Room Nursing Staff


3. Anaesthetists.


3. Anaesthetists.

No.


3. Anaesthetists.


Barriers to Change.


Barriers to Change.

▪ 1. Nostalgia.


Barriers to Change.

▪ 1. Nostalgia.

▪ 2. Denial.


Barriers to Change.

▪ 1. Nostalgia.

▪ 2. Denial.

▪ 3. Arrogance.


Barriers to Change.

▪ 1. Nostalgia.

▪ 2. Denial.

▪ 3. Arrogance.

Disclosures.

▪Honoured.



indicator).






▪SOLUTION: ”Let’s do a study.”


2. Evaluation & Investigation.

▪“Failure of Oxygen Delivery Audit”.

FOD AUDIT METHOD.

▪ *Anaesthetic nurse recruited to passively observe the process of supplemental oxygen delivery via Hudson mask from first application of mask in OR (cylinder) to transition to alternate source in PACU (wall outlet).

▪ Activation and flow of oxygen was confirmed by *Anaesthetic nurse once mask fitted to patient.

▪ Where NO FLOW of oxygen to mask unrecognised for 15 seconds → Anaesthetist notified and flow activated.

▪ Observation of Oxygen delivery continued by *Anaesthetic nurse until mask connected to activated wall outlet in PACU.

▪ Where NO FLOW of oxygen to mask unrecognised for 15 seconds → Anaesthetist/PACU Nurse notified and flow activated.

FOD AUDIT METHOD.

▪Any instance of NO OXYGEN FLOW to mask for 15

seconds or more unrecognised by Anaesthetist or PACU

Nurse without prompt by *Anaesthetic Nurse deemed to

“Notable Audit Event”.

Failure of Oxygen Delivery Audit.

▪ 511 cases surveyed.


▪ 511 cases surveyed

▪ 32 patients had a least one ‘reportable event’ of unrecognised

failure of oxygen delivery.





▪ Prevalence of 6.3% (95% CI 4.52-8.79).





▪ Prevalence of 6.3% (95% CI 4.52-8.79).

▪ 20 events in GOR





▪ Prevalence of 6.3% (95% CI 4.52-8.79).


▪ 7 events in PACU





▪ Prevalence of 6.3% (95% CI 4.52-8.79).



▪ 1 event during Transit from GOR to PACU





▪ Prevalence of 6.3% (95% CI 4.52-8.79).




▪ 2 incidents in both GOR and during Transit to PACU





▪ Prevalence of 6.3% (95% CI 4.52-8.79).





▪ 1 incident in both GOR and PACU





▪ Prevalence of 6.3% (95% CI 4.52-8.79).






▪ 1 incident in GOR, Transit and PACU!!!



▪ 32 patients had a least one ‘reportable event’ of unrecognisedfailure of oxygen delivery.

▪ Prevalence of 6.3% (95% CI 4.52-8.79).






▪ 1 incident in GOR, Transit and PACU!!!

▪ *Cumulatively 37 individual episodes of unrecognised failure of oxygen delivery.








▪2019 ANSWER = “YES”.








Causes.


1. Equipment


2. People


1. Equipment.


1. Equipment


2. People / Human Factors.



▪“Human Factors” considers relationship between

human beings and the system with which they

interact.



▪ Job Factors:

- System/ Equipment variation.

- Divided attention.

- Time pressure.

- Communication.

- Working environment (Noise, Space, Lighting, Positioning).



▪ Job Factors:



- Time pressure.

- Communication.




▪ Job Factors:



- Time pressure.

- Communication.




▪ Job Factors:



- Time pressure.

- Communication.




▪ Job Factors:



- Time pressure.

- Communication.




▪ Person Factors:

- Physical capability or illness.

- Fatigue.

- Stress/Morale.

- Work overload.

- Competence.

- Motivation vs other priorities.







Unrecognized Failure of Oxygen Delivery to Patients.

Mitigating Risk of Errors.

• 1. Training and Education.


Mitigating Risk of Errors.

• 1. Training and Education.

-Problems and case reports re-emerged within

30 days.


Mitigating Risk of Error.

• 2. Standardised oxygen Cylinders with

Re-Training and Education.



• 2. Standardised oxygen Cylinders with

Re-Training and Education.

-Problems and case reports re-emerged within

30 days.



• 2. Standardised oxygen Cylinders with Re-Training and Education.

-Problems and case reports re-emerged within 30days.



Job Factors:

-System/ Equipment variation.

-Divided attention.

-Time pressure.

-Communication.

-Working environment (Noise, Space, Lighting, Positioning).

Person Factors:

-Physical capability or illness.

-Fatigue.

-Stress/Morale.

-Work overload.

-Competence.

-Motivation vs other priorities.



Unrecognized Failure of Oxygen Delivery.

SureflO2™


SureflO2™

Unrecognized Failure of Oxygen

Delivery.

SureflO2™









• 1. The sentinel event. ✔






• 1. The sentinel event.✔

• 2. Is there really problem?✔







• 3. Why is there a problem?✔






• 3. Why is there a problem?✔

• 4. Risk mitigation?... Perhaps?


THANK YOU.

Documents

Unrecognized Failure of Oxygen Delivery to Patients. · 32 patients had a least one ‘reportable event’ of unrecognised failure of oxygen delivery. Prevalence of 6.3% (95% CI 4.52-8.79)