Intra-hospital transfer: Human error and safety concerns with improper setting up of a cylinder-based oxygen delivery system.

Sir,

Incident reporting is a key factor in maintaining patient safety in the perioperative scenario. We report an incident of near miss due to human error in an intra-hospital transfer (IHT), which was averted due to the strict adherence to protocols and checklist implementation during the pre-transport phase.

A post-thoracotomy patient was to be shifted to the Intensive Care Unit from the operation theatre (OT) on Bain's circuit with a trolley-mounted oxygen cylinder for elective post-operative ventilation. When the anaesthesiologist performed his routine pre-transport check, it was noticed that the standard flowmeter assembly on the oxygen cylinder [Figure 1a] was modified by using a L connector instead of the glass tube. In addition, the regulator knob was found to be defective and completely free [Figure 1b]. When the valve of the cylinder was opened with a spanner, there was no movement of the needle on the regulator gauge, and oxygen was flowing at a high pressure and high flow (litres/min) through the L connector with risk of barotrauma and volutrauma.

Figure 1

(a) Normal oxygen cylinder assembly with glass flowmeter and regulator, (b) faulty setup of oxygen cylinder with the L connector and non-functional regulator and gauge

The event was investigated and discussed in departmental incident-reporting meet. In general, with a defective regulator, there is either no flow of gas or a stuck turn wheel, with incomplete opening of cylinder, both of which prevent high pressures from being transmitted to the patient.

It was found that the error was caused on that particular day because the senior anaesthesia assistant who was in charge of assembling and checking the transport trolleys was busy shifting two other patients and so his work was taken over by a relatively inexperienced technician. It was the practice to assemble the shifting trolley only when demand was raised from the OTs. Post this incident, protocol for IHT was revised so that now, all patient transfer trolleys are kept ready at the beginning of the day by the senior technician in charge. In addition, we have increased the number of IHT trolley assemblies and these are all kept in a designated secure place where they cannot be tampered with. The anaesthesiologist in charge of the case to be transferred personally checks each system again before connecting the patient to it.

An incident is an outcome or event which can jeopardise the safety of the patient. Beckmann et al. in an analysis found that 39% of incidents were attributable to equipment problems and 61% to patient and staff management issues including incorrect setup of equipments during IHT.[1] The United kingdom (UK) National reporting and learning system data from 2006 to 2008 revealed that most incidents were as a result of failure of equipment/device and about 0.08% of the incidents occurred due to inadequate check of the equipment and supplies.[2] Our case, according to the UK's National Patient Safety Agency (NPSA) definition, comes under ‘preventive patient safety incident category‘ i.e., prevention of an unexpected and unintended incident, so no harm should occur.[2] Three phases of transport are suggested for critically ill patients, as part of check list i.e. pre-transport, during transport and post-transport phases.[3] Fanara et al. described IHT-related risk factors, of which equipment, team and organisation were the most common determinants.[4] To conclude, the IHT of a patient is fraught with chances of adverse events. The need is for better pre-transport planning with comprehensive training of all the personnel involved in the IHT with strict adherence to the standardised procedures, guidelines and checklists for all the phases of transport.

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Conflicts of interest

There are no conflicts of interest.