Tuesday, August 02, 2016

Just Stop This Blame Rubbish! It Is Totally Clear Who Is To Blame!

I am a specialist anaesthetist.

On this nonsense of who is responsible for the gas mess up disaster at a Sydney Hospital it is utterly clear.

Some utterly incompetent and utterly guilty person did not check what gas was coming out of each pipe in the Hospital.

He/She needs serious jail time. You need (as a clinician) to be utterly sure what comes out when you open a gas flow - and you can hardly check every time in every place.

The engineers need to make this utterly certain and safe or go to jail.

Simple!

David

13 comments:

Anonymous said...

I am no expert but should there not be some sort of monitoring capability that machine checks this?

Dr David More MB PhD FACHI said...

Hardly ...once connected machines are used and connccted for years. The technicians need to check, be certain and we can all get on caring for our patients..

David.

Benedict 16th said...

Who is going to pay for the compliance checking, are you willing to take a 20% pay cut to help fund this???? No I don’t think so. Get off your high horse and pitch in with the rest of us... You arrogant ........

If you think I am an upstart, go to NASA (would you like me to google that for you?) and loo at their systems for problems and near misses, then come back to me.

You would be more use if you could show how this mistake happened, how it might be prevented (a cigarette lighter and some 1st year uni chemistry knowledge would help) and what could be improved. Instead of the cheapest bid to install equipment - any FU the administrator is criminally responsible? not the poor schmuck that came afterwards.

BE PART OF THE SOLUTION NOT THE PROBLEM you arrogant.......

next time you are gassing a patient I expect you to check each and every line for each and every gas, make sure its a fluorinated ... make sure its midazolam, make sure it a -uronium (check on yourself perhaps)... eacbhg and every time, and if you leave to go to the toilet, check again when you come back...

Dr David More MB PhD FACHI said...

Thanks Benedict...

When you pipe a building with gas lines, you do it once, check it twice and then rely on the fact all the pipes from the wall to the patient are made so they CAN'T be connected wrongly. Equally the machines that dispense the gases are made in a similar safe way.

It is utter negligence and incompetence that this could ever happen and it is the individual who supervised and checked the installation who is guilty. Not the company and not the hospital engineer IMVHO.

David.

Terry Hannan said...

David, I did a check on this to verify the following. The )1 and Nitrous oxide outlets have DIFFERENT fittings so misconnection cannot occur.
If this is so then where did the system go wrong? It reminds me of the quote. "Most care accident are caused by the loose nut behind the wheel".

Andrew McIntyre said...

Its a horrific situation because the last thing you would want to do is take a patient doing badly off Oxygen, and the level of suspicion that the oxygen is not oxygen would be incredibly low.

I think however its one of those events that is hard to prevent, its probably related to an unusual series of minor errors that all lined up in a row and allowed a catastrophe to occur. It happens with air crashes, the safety mechanisms are supposed to stop errors but you can never be 100% and there is usually a very low probability path through the safety mechanisms. However low the probability is it can still happen, which is very sad. However its possible that no one made any terrible decision, but a combination of minor oversights lined up. We have a culture of blame however.

I would strongly suspect that eHealth is much more of a risk as the quality is low at many levels and a path to serious error would be much easier to find!!! I am sure it has happened many times. This appears to be a blind spot of the administrators as they have no understanding of technology.

I don't think all errors can be 100% prevented however and we need to await the investigation as its possible that this is just a low probability bad outcome that has no single point of failure.

Garry said...

Why not have slightly different fittings for different gases? A small investment to solve a problem that has produced devastating consequences.

Benedict 16th said...

Thank you for the level headed reply (not a compliment)
How about - who does the ‘buck’ stop with?
1/ https://www.projecttimes.com/george-pitagorsky/failed-projects-who-is-responsible.html (maybe surgeons shouldn’t be ‘project leaders’ and accept they are part of a team)
2/ esoteric, but if you need, I can substitute nouns and adjectives.... http://guweb2.gonzaga.edu/faculty/alfino/dossier/presentations/97_SBE_Business_Failure_and_Corporate_Managerial_Responsibility.htm
3/ But of course.... it reminds me of the old joke
What is the difference between God and a Surgeon?
God doesn’t think she is a surgeon
http://adevotion.org/archive/why-do-bad-things-happen-01

Garry Boyd said...

It's a simple problem to fix ....... different gases should have slightly different fittings so they simply cannot be confused. I'd question why this has never been done. It's not rocket science but, ahhh.........perhaps it's an 'unnecessary' cost?

Anonymous said...

Dear Dr Anesthetist - Surely there is a universal standard with fittings specific for each gas to be piped. If Nitrous Oxide has one [specific male-female combination fitting, another gas had another male-female combination fitting, then the problem surely would not have arisen unless the wrong gas was in the wrong bottle. Does the manufacturer and the health system not have such basic solutions in place when providing gases which potentially can be life threatening.

Anonymous said...

I've lodged a couple of comments the last few das but they don't seem to be getting through.

Andrew McIntyre said...

The fittings are different and you can't connect them wrongly. The error has been in the plumbing from what I understand, with a nitrous line wrongly labeled as oxygen. Its terrible, but we need to await the investigation...

Anonymous said...

My understanding is that with 100% nitrogen the patient rapidly desaturates their O2, and turns 'black'. I was speaking to a senior anaesthetic colleague who has been involved in writing the safety standards for the profession, and he said in this case the standard of practice is absolutely clear. One immediately disconnects the patient from the anaesthetic machine, and gives them room air to breath whilst trying to work out what is going wrong at the machine end. The practice standard exists precisely because it takes time to work out what the problem with the machine is. So, despite it obviously being a major failure at the point of gas connection, it does appear that there were things that could have been done that are standard modern anaesthetic practice.