Preventing Flowmeter Misconnections
From time to time patients have been mistakenly connected to an air flowmeter instead of oxygen with significant impact on the patient's condition. This has been a documented issue over many years[1]. At Flinders Medical Centre, a 2 year study of incidents was undertaken. 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
Air and oxygen can be incorrectly connected to patients as the flowmeter connectors are the same size.
The most common factors were:
• 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. |
 Cluttered bedside |
• 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 Options
A multi disciplined team considered error proofing and error reduction options:
Error proofing options were:
- Create an incompatible connector system.
- The best solution, but needs to be done on a national or greater scale and involves large costs and delays. Will not produce a rapid solution. - 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.
- Remove all air flowmeters & supply nebulisers to all wards.
Management issues such as:
- Sharing pumps between patients.
- Need to locate 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 two outlets per bed.
- Patient distress or complaints as medication may be delayed.
These may also impact staff morale.
Error reduction options included:
- Educate staff to remove all air flowmeters when not in use.
- All flowmeters will not be removed if staff are busy. The event could recur. - Develop a device to alter the connection process.
The Adopted Solution
Developing a device to alter the connection process to medical air flow that creates a strong visual / physical barrier 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.
• A Patient Safety Alert was developed and promoted to medical & nursing staff.
These devices were distributed throughout the hospital in July 2007 & the system is awaiting evaluation.
The Device
The air flowmeter is fitted with the device, the oxygen flowmeter remains unchanged.
The label and front panel are always positioned at the front of the flowmeter.
Clearly labelled.
Looks obviously different to oxygen outlet.
Requires different process 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 Device - AirGuard (Mouse-over to see making the connection) |
The Results
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. 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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