1. Minimizing misconnections to Medical Air
Submitted by
Name: Mark McEwen, Anne-Louise Smith
Affiliation: CED Collaborator
National association (if exists): SMBE, Society of Medical & Biological Engineering
Location: Adelaide, South Australia
address for contact:

2. Country Estimates in Brief Please fill the statistics you can find
Population
Australia 24M
South Australia 1.7M
Population Growth Rate
Australia 1.3%
South Australia 0.7%
Life Expectancy at Birth
80.3 male, 84.4 female
Infant Mortality Rate
3/1000 live births under 1 yr
Number of Health Centers in Country
747 public hospitals
612 private hospitals
Total Expenditure on Health as % of GDP
9.1%
Global CE / HTM Success Stories

3. Global CE / HTM Success Stories
Country's Health Technology Program Minimizing misconnections to Medical Air
The hospital Safety & Quality department had reports of patient incidents where oxygen was supposed to be provided to the patient but they got medical air instead
Patients required many days in ICU to restabilise
An expert panel was created with medical, nursing and biomedical engineers to investigate the root cause of the problem
The panel reviewed the reported incidents, undertook a literature review, interviewed staff, visited the clinical units and audited the medical gas set up
The most common error was: Reconnection to air rather than oxygen 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 with incorrectly colored outlets; only white (oxygen) were available from stores, and no black (air) outlets
January 2016
Global CE / HTM Success Stories

4. Country's Health Technology Program Next Steps for Success Story
The hierarchy of risk mitigation was used to assess possible improvements
Error proofing could not be done without a change in standards, so an error reduction strategy was used
Biomedical Engineering developed a visual/physical barrier for medical air outlets, Air Guard
Had to consider infection control, ability to be cleaned with alcohol, emergency use
Final device fitted to medical air outlets providing a freely hanging label that needed to be moved to attach hose to medical air and left oxygen unchanged
A trial was conducted to determine if incidents due to misconnection of gases were reduced and ensure no other incidents were introduced
January 2016
Global CE / HTM Success Stories

5. Conclusions and Action Plan
Improved patient outcomes, over a 2 year period
Before Air Guard, 12 patients at one hospital had reported incidents being treated with medical gas (instead of oxygen)
After Air Guard, 3 patients had reported incidents (one from an area that didn’t have the AirGuard)
Cost for fitting out a hospital was equivalent to 1 patient day in Intensive Care
The device has been made for other hospitals in Australia, Canada, USA, UK & Denmark
January 2016
Global CE / HTM Success Stories