on 26-07-2016 07:21 PM
A devastating error at a southwestern Sydney hospital has left one baby dead and another seriously brain damaged, the NSW Health Minister Jillian Skinner has confirmed.
"I am profoundly sorry for the families of a newborn who died and another newborn who was severely affected after the wrong gas was dispensed through a neonatal resuscitation outlet at Bankstown-Lidcombe Hospital," Ms Skinner said in a statement on Monday evening.
The babies, who were born in the last two months, were accidentally given nitrous oxide instead of oxygen.
I can't begin to imagine how devastated the family must be and the paint they're going through.
Also the medical staff who were involved in the incident.
News reports are saying it was due to an error in the installation of the gas connection.
"The legal General Council for NSW Health has since written to the private company, BOC Limited to find out how the error occurred.
The South Western Sydney Local Health District is also conducting a formal investigation into the staff at the hospital, to see if they could have detected the error."
on 28-07-2016 07:26 PM
i had not even thought of that, good thinking.
ive no idea even what these bottes would look like or if the attachments on the actual bottles are different between gasses.
on 28-07-2016 08:33 PM
David, I suggest you go back and read tippy*toes post where she explains how it is impossible to connect incorrect tubing to a gas outlet. That would seem to indicate that it is also impossible to connect the wrong gas cylinders in the first place.
Which would indicate that the cylinders were filled incorrectly.
It will be interesting to see what does come out of the enquiry.
on 28-07-2016 09:27 PM
https://en.wikipedia.org/wiki/Gas_cylinder
Nitrous oxide | BS | 13 |
Oxygen | BS | 3 |
The SOP afaik When a new bottle is fitted is that the available flow and veracity of the contents are supposed to be
checked and signed off by a senior clinician.
A bottle may have been filled with an incorrect gas.... even a wrong fitting may have been fitted during refurbishment
... however....
those mistakes should have been picked up if the above SOP was adhered to.
It is a fail safe system that is used in many industries other than the medical industry
https://smah.uow.edu.au/content/groups/public/@web/@ohs/documents/doc/uow136686.pdf
NOTE: Cylinder valves on flammable gases have a left hand thread to attach the regulator.
This is to distinguish them from non flammable gases.
The thread size of an Air or Nitrogen cylinder valve differs from Oxygen so that they
cannot be mistaken in medical applications.
on 28-07-2016 10:25 PM
http://www.afcintl.com/g210-n2o-and-oxygen-medical-gas-analyzer-4.aspx
I wonder whether the SOP deems that the label of the bottle is checked when fitted by the clinician or if one of the above
analysers is used at the outlet after fitment.and also pressure gauge to verify flow rate
It would appear to me that the instrument above would pick up both a wrongly originally plumbed/ wroungly repaired gas
line or a incorrectly filled bottle.
29-07-2016 04:00 AM - edited 29-07-2016 04:03 AM
I was referring to pipeline gases where the outlets are on the wall or hanging from the ceiling. Portable cylinders, that's another story. The connections are the same on the bottles. That said, there is a distinct difference in colours on the bottles that are pretty hard to miss. Like the pipeline outlets, they are coloured the same way. People need to be more diligent when checking because I saw an oxygen bottle get connected to a device that is meant to have CO2, which could have had catastrophic consequences for everyone.
There should be a SOP stating that all portable cylinders be checked by 2 people, same as drugs, but sadly, there's not. Although anyone worth their salt should be able to tell the difference between a white cylinder and a blue one, or a green one, or a black and white one. There is no excuse for mixing up cylinders.
Given that there was nitrous involved, I'd say it was a pipeline job because portable nitrous cylinders aren't routinely stored (they get nicked!). If you want one, you have to special order it.
I'll be interested to hear the outcome of the investigation (and try and avoid the trial by media which is inevitable. How many have called for heads to roll?)
Edit. In regards to portable bottles, they have portable bottles on baby rescus trolleys, as well as it being hooked up the pipeline. The portables are a back up or they need to transport the sick baby to a different room. Even through the connections are the same on the portable bottles, the hoses running from the bottle to the machine are colour coded. So again, no excuse. There is NEVER any portable nitrous bottles on a baby trolley.
on 29-07-2016 06:49 AM
The baby that died was being treated in the Neonatal Resuscitation Unit.
You would think it would be foolproof in there of all places.
29-07-2016 11:56 AM - edited 29-07-2016 11:58 AM
@lyndal1838 wrote:The baby that died was being treated in the Neonatal Resuscitation Unit.
You would think it would be foolproof in there of all places.
Yes the baby was being treated there after the event. The incident where the mix up took place was in the operating theatre unit NOT the NICU. Both babies had been delivered by C section and were being given what was supposed to be oxygen immediately after delivery.
O2 is often needed for babies after delivery by C section.
So behind the wall in the Operating theatre was a mix up that led to this terrible occurence.
Theatre staff can't see what's behind the walls, that is the domain of whoever installed the piping system and connected up the main cylinders outside or wherever they are kept.
This isn't the fault of the doctors and nurses in theatre.
on 02-08-2016 02:21 PM
It is reported that an engineer has been stood down.....
The State Government has released an interim report into the mix-up, stating the engineer involved in commissioning the gas line had been stood down, pending the outcome of the investigation.
The interim report also confirmed NSW Health had stopped using the company BOC Ltd for installation, commissioning and testing works at all hospitals across the state until the investigation was completed.
Health Minister Jillian Skinner said it appeared both the hospital and the company that installed the gas were to blame.
DEB