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Posted By: Chris Watts O2/Air flowmeter confusion - 25/07/14 9:23 AM
Can I check what precautions do other hospitals have in place to stop incorrect selection of O2 and Air flowmeters?

I know colour coding should be a big clue and that Therapy equipment produce an air guard for their flowmeters, but does anybody have any other precautions apart from locking the air flow meters in a cupboard?
Posted By: Sean Fearon Re: O2/Air flowmeter confusion - 25/07/14 10:02 AM
Hello Chris

You could follow the guidance in this document (Action 4):
Implementing the Rapid Response Report 'Oxygen Safety in Hospitals'

Failing that, adopt the Belt & Braces approach, Air flowmeters removed from clinical areas.
Posted By: Darkmarker Re: O2/Air flowmeter confusion - 25/07/14 12:48 PM
Chris,

We use the Therapy air guards on all off our air flowmeters, after a very disappointing discovery that clinical staff cannot tell black from white.

We also have a trust wide policy that states:
'Continue to ensure that the flow meters are removed from the wall outlet and stored in an allocated place when not in use.'

We have also recently had issues with incorrect selection of suction for use in emergency, when a Thoracic device was used, instead of the High suction required, again these devices are clearly colour coded.

So perhaps there is no hope and the basic training of clinical staff is what needs reviewing. As there are some issues that even the greatest technicians cannot solve!
Posted By: Geoff Hannis Re: O2/Air flowmeter confusion - 25/07/14 3:26 PM

Yet more "guidelines" ... and (no doubt) "lessons that shall need to be learned" (but still haven't been - and probably never will)? frown

I thought all our lovely nurses had degrees these days!

Originally Posted By: Darkmarker

So perhaps there is no hope and the basic training of clinical staff is what needs reviewing. As there are some issues that even the greatest technicians cannot solve!


Yes; indeed. smile
Posted By: Chris Watts Re: O2/Air flowmeter confusion - 25/07/14 6:49 PM
Thanks for the info, they tried removing the air flowmeters but still they come out of a cupboard and get mixed up.

You would have thought the design on the terminal would have also been a clue but it doesn't seem so.

Will probably suggest going down the air guard route, but you'd have thought there's be a few solutions out there by now.
Posted By: RoJo Re: O2/Air flowmeter confusion - 28/07/14 8:00 AM
I over heard a senior nurse in a lift complaining that the connections on the flowmeters needed to be different, after an incident occurred in our Trust.
I was thinking to myself, you mean apart from one being black and the other white, large notices stuck on the wall next to the air points and having to move the air guard to connect the hose.
Belt, braces and a piece of string but there is always someone else to blame for your stupidity.
Robert
Posted By: Spicer Re: O2/Air flowmeter confusion - 28/07/14 11:28 AM
FYI Oxylitre also supply air guards, in fact their air flowmeters now come with them as standard. Ultimately "stupid is as stupid does" - online definition: It means that an intelligent person who does stupid things is still stupid. You are what you do.
Posted By: Geoff Hannis Re: O2/Air flowmeter confusion - 28/07/14 6:20 PM

Surely the AirGuard is a far too cheap and simple "solution"? We only want expensive "high-tech" solutions here. whistle

How about a personalised oxygen meter for each nurse? Surely there must be an "app for that"? think
Posted By: Darkmarker Re: O2/Air flowmeter confusion - 29/07/14 11:37 AM
If it's the high-tech you are after Geoff, then surely some sort of proximity sensor attached to the gas outlets/flowmeters setting off an alarm, flashing lights whenever anyone approaches them. As well as automatically sending the current hospital guidelines for delivery of medical air/oxygen to their smartphone and updating their social media accounts with a second by second account of what they are doing?
Posted By: Neil Porter Re: O2/Air flowmeter confusion - 29/07/14 11:43 AM
Darkmaster, you could have the jingle from 'Family Fortunes' beep out everytime they try to insert the wrong flowmeter.
Posted By: RoJo Re: O2/Air flowmeter confusion - 29/07/14 11:55 AM
The problem is that everything is set up correctly mechanically then you add a human who puts the tube on the wrong spigot and turns on the wrong knob.
If you really want a project it is a "I might have done that but I meant to do this" thought recognition app.
Only when the person and not the equipment gets the blame, then we might see people taking a little more care.

A nurse in intensive care at a hospital I worked was with a patient who was "going off2 and was told to increase the infusion rate of a certain drug, she adjusted the wrong pump which had the opposite to the desired effect so was told to increase it more, this happened a few times with the patient eventually dieing.
The coroner's recommendation - this class of drug should be given through a unique pump so it can be easily identified....... not that the nurse should check what she was doing.
No matter how much technology is used you still have people operating it.
Robert
Posted By: Geoff Hannis Re: O2/Air flowmeter confusion - 29/07/14 7:01 PM

Originally Posted By: Darkmarker

... updating their social media accounts with a second by second account of what they are doing?


Aren't they doing that themselves, anyway?

That's probably why they are being "distracted" when carrying out simple tasks. frown
Posted By: Electric Blobby Re: O2/Air flowmeter confusion - 15/08/14 7:16 PM
if you are talking about the colour then this should be obvious and sorry to state this however If you are worried about the oxygen being inserted air and vica Vedas they are keyed to be different in the probe diameter and this cannot be crossed as they physically will not fit. Refer to the him 22 guidance as I am sure I am correct and if not shot me... Last of all we have more issues with low and thoracic suction and the reasons for use but have a rubbish training department who have a boc training package for the online staff training and therapy through the trust. Makes sense NOT! But who are we to comment
Posted By: Geoff Hannis Re: O2/Air flowmeter confusion - 16/08/14 7:39 AM

I should imagine we are talking about connecting the face mask (etc.) tubing to the spigot on the (wrong) flowmeter. smile
Posted By: Electric Blobby Re: O2/Air flowmeter confusion - 03/12/14 7:16 PM
Apologies for the previous 'smelling' and grammar but I have seen that Therapy sell a probe entry system that is basically a flap of plastic in white or black. Before you insert the probe you have to lift the flap 'clearly stating the gas type' and if they are lost from there then give them a cigarette and bottle of o2 and sing a song.
good luck
Paul
Posted By: KM Re: O2/Air flowmeter confusion - 04/12/14 8:02 AM
So we have
1. AP/CP/Pharmacy QA system of setting up MGPS.
2. MGPS that is indexed at the outlet so you know you only get what you want out at the terminal end.
3. Device thst is indexed to only fit into the MGPS.
4. Device that is colur coded and marked to the gas it gives.
4. Device that is now fitted with a cover that needs to be lifted to show you have accepted what you want.
Lets get real if thry still get it wrong and to the extend that patient obs still dont indicate to the professional user / prescriber of the drug (O2 is a drug) then take me to the vets hospital next time im ill.
Posted By: Geoff Hannis Re: O2/Air flowmeter confusion - 05/12/14 2:37 PM

Yes, oxygen is a drug (or always used to be considered as such, at least). whistle

Just out of interest:- Does it get prescribed? And do details (flowrate, duration etc.) get entered in patients' notes?

And what about "home use" (or even "private", "personal", whatever) ... how is that meant to be controlled, I wonder? think
Posted By: KM Re: O2/Air flowmeter confusion - 15/12/14 8:22 AM
Yes it should be prescribed (logged), or else how do you know how they are getting better or worse if SATS, ECG, BP or whatever else you are monitoring etc drop or increase.
Community based patients (and or their carers)should be given documented training on what to do, who to contact if there is a problem etc.
As far as private goes, there are thousands out there on variuos devices and suppliments that havent been prescribed by a healthcare professional you cant be responsible for these candidates if they decide to do what they want in confinement.
Other than legislating to stop the purchase.
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