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Check Out Medical Equipment When Small Shocks Reported

March 20, 2008
Written by: , Filed in: Practice Management
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Two environmental ‘never events’ include patient death or serious disability
linked to either an electric shock or the switching of lines designated for
oxygen with the wrong gas while being cared for in a health care facility.

Six major categories of preventable medical errors are incorporated into the
National Quality Forum’s list of 28 ‘never events.’ One of these major
categories is environmental events, which include items such as electrical
shock, fires, and switched gas lines. The first item in the environmental
events category is patient death or serious disability associated with an
electrical shock while being cared for in a health care facility. This is a
very rare event.

When investigating cases of electrical shock, we find that typically there
were hints that the health care team did not take seriously before the actual
patient shock. Therefore, when staff members report getting a shock when
touching a piece of equipment, do not always assume that the problem is static
electricity.

The assumption of static electricity being the causative factor is not a great
conclusion to draw when touching medical equipment. If you get a shock, or if
the patient talks about feeling tingles or anything similar, stop and have
that piece of equipment investigated regardless of how “off the wall” the
request may seem at the time.

The second item on the list of environmental events is any incident in which a
line designated for oxygen or another gas to be delivered to a patient
contains the wrong gas or is contaminated by toxic substances. Probably the
most frequent switch seen is oxygen and carbon dioxide (CO2). Meters used to
deliver oxygen and CO2 are different colors, and they are not interchangeable.
However, the tubing used to deliver these gases can be interchangeable, which
is where the error usually occurs.

Oxygen is typically delivered off of a green meter and CO2 is delivered off of
a yellow meter, but the equipment that attaches to these meters is comparable.
Therefore, it is not unheard of to switch the two gases, which can be
devastating for the patient.

There are also some reported cases of switches with anesthetic gases that can
be problematic. On rare occasions, you will have contamination of a tank line,
which can be picked up in many ways. With contamination at that level, you are
going to be delivering gases to a large number of patients, and the health
care team picks up quickly on what is happening. All these types of incidents
are considered a ‘never event.’

Reference:
Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Two Never Events:
Electric Shock and Gas Line Delivery Errors

Two environmental 'never events' include patient death or serious disability linked to either an electric shock or the switching of lines designated for oxygen with the wrong gas while being cared for in a health care facility. Six major categories of preventable medical errors are incorporated into the National Quality Forum's list of 28 'never events.' One of these major categories is environmental events, which include items such as electrical shock, fires, and switched gas lines. The first item in the environmental events category is patient death or serious disability associated with an electrical shock while being cared for in a health care facility. This is a very rare event. When investigating cases of electrical shock, we find that typically there were hints that the health care team did not take seriously before the actual patient shock. Therefore, when staff members report getting a shock when touching a piece of equipment, do not always assume that the problem is static electricity. The assumption of static electricity being the causative factor is not a great conclusion to draw when touching medical equipment. If you get a shock, or if the patient talks about feeling tingles or anything similar, stop and have that piece of equipment investigated regardless of how "off the wall" the request may seem at the time. The second item on the list of environmental events is any incident in which a line designated for oxygen or another gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. Probably the most frequent switch seen is oxygen and carbon dioxide (CO2). Meters used to deliver oxygen and CO2 are different colors, and they are not interchangeable. However, the tubing used to deliver these gases can be interchangeable, which is where the error usually occurs. Oxygen is typically delivered off of a green meter and CO2 is delivered off of a yellow meter, but the equipment that attaches to these meters is comparable. Therefore, it is not unheard of to switch the two gases, which can be devastating for the patient. There are also some reported cases of switches with anesthetic gases that can be problematic. On rare occasions, you will have contamination of a tank line, which can be picked up in many ways. With contamination at that level, you are going to be delivering gases to a large number of patients, and the health care team picks up quickly on what is happening. All these types of incidents are considered a 'never event.' Reference: Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Two Never Events: Electric Shock and Gas Line Delivery Errors [text_ad]
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