ECH 5511 Safety, Health and Environmental Protection

Semester 1 2011/2012

Assignment 1

The administration of Serdang Hospital was quite excited about renovating several of their operating rooms, but also very concerned about the potential cost of the process. They attempted to save money at every opportunity, carefully selecting the lowest bids on every purchase and contract. The head of the purchasing and contract department was anxious to demonstrate his efficiency in saving money, and failed to spend time evaluating the quality records of the companies submitting the bids (a defeated defense). Once the renovation was complete, a safety team was called in to inspect the operating rooms. They completed inspection of Room 1 and were halfway through the inspection of Room 2 when lunch time arrived. After lunch break, one of the crew decided to take the rest of the day off, without reporting off on his progress in Room 2. The rest of the team believed that the inspection of Room 2 was complete (a failed handoff and defeated defense). Soon the rooms were open, and the first patients were admitted for surgery. The administration was particularly proud of the centrally piped medical gas system delivering oxygen and nitrous oxide to the operating rooms. The first procedure in Room 2 was an elective surgery under general anesthesia. During the surgery, the pulse oximeter slipped off the patients finger. The anesthesiologist could not easily access the patients hand to replace the oximeter sensor. The rest of the surgical team were involved in the surgical procedure, and the sound of the alarm blended in nicely with the music piped into the operating room, so they didnt hear it (a defeated defense). Since this was a stable patient, the anesthesiologist turned off the oximeter alarm rather than try to access the sensor to reconnect it (a defeated defense). Shortly afterward the patients pulse increased sharply, and the oxygen analyzer indicated a decreased oxygen flow. The anesthesiologist increased the oxygen flow, but the patient became clearly cyanotic and her pulse and blood pressure were now dropping rapidly. The sensor for the pulse oximeter was replaced on the patient, and it indicated the patient was seriously hypoxic. When she developed arrhythmias, she was disconnected from the breathing circuit and bagged from a free standing oxygen

cylinder in preparation for a code. However, once connected to the cylinder the patient rapidly improved to a normal O2 saturation level. The procedure was rapidly completed and the patient transferred to the recovery room (a near-miss). Room 2 was scrubbed and the next patient was transferred in. This patient also required general anesthesia, and quickly followed the same pattern of desaturation as the previous patient. The anesthesiologist, aware of the events of the previous case (an effective handoff and defense), immediately removed the patient from the breathing circuit and placed him on oxygen delivered from a cylinder.

Room 2 was closed until the oxygen delivery system could be further evaluated. The first step was to analyze the oxygen being delivered through the medical gas system. This showed that no oxygen was being delivered through the oxygen outlet. Close inspection of the system revealed that the pipes had been reversed during construction: oxygen was being delivered through the nitrous outlet, and nitrous was being delivered through the oxygen outlet.

Having considered the above, carry out the following:

1. Analyse the above accident using the Human Factor model, System Model and

Domino Theory. What are your recommendations to prevent the accident occurring again?
2. Discuss which, if any, of the above techniques was most useful in analysing the above

accident and which led to the more positive recommendations with regard to accident prevention.

Due date: 20 April 2012