# NCPS TIPS -- March 2001

### Contents: 1. Patient Safety Training Ideas

> 2\. Assessing the Environment of Care: Potential Electrical Shock
>
> 3\. O~2~ and CO~2~ Bottle Confusion
>
> 4\. Japanese Healthcare Organizations Visit NCPS
>
> 5\. New NCPS Logo
>
> 6\. Safety Spotlight
>
> 7\. Learning Links

### 

### 1. PATIENT SAFETY TRAINING IDEAS

##### From the VA National Center for Patient Safety

All full-time VHA employees are now required to receive 40 hours of
continuing education training annually -- of which 20 hours should be
devoted to patient safety education. Some of you have asked us for ideas
on how to meet this requirement, so here are a few suggestions we have
come up with:

Use time spent as an RCA team member

Interactive CD training (such as the modules that can be added to
Synquest)

View patient safety videos

Use web-based training

Give credit for reading selected patient safety related
articles/publications

Provide traditional face-to-face training

Use time spent at patient safety meetings

Credit time spent at patient safety related conferences

Organize mini (brown bag) training sessions

Set up poster sessions and award time spent attending (this could be
in conjunction with the safety fair many hospitals organize)

Credit time spent participating in patient safety activities related
to the physical plant safety (fire drills, emergency preparedness
drills, etc.)

This list is certainly not exhaustive. Please let us know if you come up
with additional methods so that we can share them with everyone.

### 2. ASSESSING THE ENVIRONMENT OF CARE: POTENTIAL ELECTRICAL SHOCK

##### From the VA National Center for Patient Safety

Many of our hospital sleeping rooms have small televisions mounted on
articulating arms serving each patient bed. These televisions generally
operate at 12 to 24 volts direct current (DC) with the power often
supplied to the unit through a coaxial cable which also carries the
television signal. The coaxial cable is connected to a transformer and
is generally located in a nearby wall. Power (120 volts alternating
current) for the transformer is supplied via an electrical cord that is
plugged into a wall receptacle.

There was a close call recently when an Alzheimer's patient grabbed and
pulled out the electrical cord supplying power to the transformer. The
cord was pulled out even though strain relief was provided at the point
of connection to the transformer. This action resulted in exposed,
energized, electrical wires in the immediate vicinity of the patient.
This incident resulted in only minor burn marks on the floor; however,
the results could have been fatal. The electrical circuit breaker
protecting the wiring system supplying the wall receptacle did not
operate. However, it was operating properly. The primary purpose of a
circuit breaker is property protection. Circuit breakers are designed to
operate if the current demand exceeds a preset amount (27 amps in this
case). In this incident the current draw did not exceed 27 amps and the
breaker did not operate. An electrical shock exceeding 50 milliamps of
alternating current (1 amp equals 1000 milliamps) can be fatal.

Root cause/contributing factors for this incident included care plans
not tracking trends in the patient's behavior and the electrical cord
being within the grasp of the patient. Actions that may be taken to
eliminate or control this potential shock hazard include installing
Ground Fault Circuit Interrupter (GCFI) receptacles or breakers, and
modifying the electrical power cord. The electrical cord supplying power
to the transformer could be shortened and installed in conduit or wire
molding. Selection of the most appropriate corrective action will depend
on the specific circumstances related to the patient's condition and
environmental factors.

![](media/image1.jpeg){width="1.3756944444444446in" height="1.6in"}

*A typical hospital television mounted on an articulating arm.*

### 3. O~2~ AND CO~2~ BOTTLE CONFUSION

##### From the VA National Center for Patient Safety

CO2 is routinely used during the provision of patient care in a number
of clinical settings such as radiology, anesthesiology, and laparoscopy.
Because of a lack of knowledge regarding specialized regulators designed
to deliver CO2, an O2 regulator fitted with a universal adapter to
override the safety pin index was placed on a CO2 tank to be utilized
during a procedure. The standard color for CO2 tanks is gun metal gray;
however, in some cases CO2 tanks are old green tanks that have been
painted battleship gray. These gray-green "E" cylinder-sized tanks had
been lined up next to oxygen "E" cylinders. The CO2 cylinders
incorrectly had O2 regulators attached. Following a medical procedure a
patient was transported for follow up imaging. This patient needed O2.
On this day a CO2 tank was inadvertently picked up and used during the
patient transport instead of O2 creating a hazardous situation.

The FDA database has indicated this is not a unique event. This event
proved to be revealing and is being shared in the hopes of preventing a
similar occurrence elsewhere. Lessons learned include:

• Never modify regulators to defeat the safety interlocks

• Do not use universal adapters and ask your Pulmonary Division to
control all universal adapters

• Work with vendors and manufacturers to provide the safest product for
your patient.

• Ensure that all compressed gas cylinders and containers are labeled in
accordance with Compressed Gas Association C-7, *Guide to Preparation of
Precautionary Labeling and Marking of Compressed Gas Containers*. Labels
and placards are more effective than color as cylinders are often
subject to abuse that can wear off the paint making identification of
the original color difficult. The color of the tank can also appear
different dependent upon the lighting conditions.

• Control your compressed gas inventory along with your regulators.

• Train all staff who work with compressed gas cylinders on the
standardization of color, regulators, and the Pin Index Safety System.

Manufactures do make specialized regulators, for example VERIFLO makes a
specialized CO2 regulator (960094) that is designed to provide CO2 gas
by volume. If you are using CO2 tanks equipped with oxygen regulators
--- **STOP**!! Contact your compressed gas dealer who can help you
locate the appropriate equipment. And last but not least, encourage your
staff to READ the labels. **Right patient. Right Intervention. Right
Gas.**

*To learn more about this topic see the July/August 2000 FDA Consumer
Magazine article "Avoiding The Hazards Of Medical Gases"*
([www.fda.gov/fdac/features/2000/400_gas.html]{.underline}) *and the
Compressed Gas Association's website*
([www.cganet.com/Publication_Selector.asp?mode=free)]{.underline} *which
shows the latest industrial gas safety information available covering
the proper manufacture, handling, and use of industrial gases and
cryogenic liquids.*

### 4. JAPANESE HEALTHCARE ORGANIZATIONS VISIT NCPS

##### From the VA National Center for Patient Safety

Japan recently sent several delegations of healthcare officials to the
U.S. on patient safety fact-finding tours. This past month, NCPS was
visited by two of these groups.

Officials from Japan's Department of National Hospitals, National
Cardiovascular Center, and the Japan Council for Quality of Health Care
(their equivalent of JCAHO) visited NCPS and were given an overview by
NCPS staff members about the VA's patient safety processes and
information systems. This was followed by a general discussion of
patient safety issues.

The visit of these two prominent healthcare delegations is further
indication that the VA's patient safety program is gaining international
stature and being used as a role model for other healthcare
organizations both here and abroad.

### 

### 5. NEW NCPS LOGO

##### From the VA National Center for Patient Safety

![](media/image2.jpeg){width="3.251388888888889in"
height="1.5243055555555556in"}

We're proud to unveil the new NCPS logo. The logo was based on ideas
from the NCPS staff and Andrew Scheller, a visual illustrator from the
Philadelphia VAMC. It was intended to capture the essence of what we are
all about -- patient safety. Using the traditional green "safety cross,"
we have also added the Staff of Aesculapius (the traditional symbol of
medicine) to it and have the color of the lettering in the logo blue,
the color often associated with VA healthcare.

### 

### 

### 6. SAFETY SPOTLIGHT

##### From the VA National Center for Patient Safety

(On a regular basis we will feature teaching examples pulled from
medical literature and similar RCAs that we feel are applicable and of
interest to the entire VHA healthcare system. These cases are intended
to be used for learning purposes only.)

#### MRI Near Miss

Description

**Case #1**. The patient was taken to an MRI room for imaging. After the
MRI, the patient was transferred from the MRI couch to a stretcher in
the magnet room. Unknown to the technologist, the IV pole on the EC
stretcher was of a ferro-magnetic material affected by the magnet. The
IV pole was pulled into the magnet gantry, narrowly missing the
technologist and the patient. The patient and stretcher were removed
unharmed from the MRI. No damage occurred to the MRI.

**Case #2**. The patient was placed on MRI couch to begin the MRI
procedure. A sandbag encircled the patient's arm to control tremors.
Unknowingly, this sand bag contained ferro-magnetic materials. The bag
was pulled to the magnet, pinning the patient's arm to the MRI with
several hundred pounds of force. The technician followed emergency
shutdown procedures to free the arm. There was no permanent harm to the
patient. (Of note, each time there is an emergency shutdown it can cost
from \$20,000 to \$40,000. If the magnet core is damaged from an
emergency quenching this can cost up to \$500,000.)

Vulnerabilities

MRIs and MRI suites have been identified as system vulnerabilities by
manufacturers, the Food and Drug Administration (FDA), and the Emergency
Care Research Institute (ECRI). Vulnerabilities include:

Exposing materials that we presume are not affected by the magnet
(e.g., sand bags) but are in fact a risk

Sandbags may contain ferrous elements to increase the weight of the
bag without added bulk, without any labeling about the contents

Transferring from stretchers to MRI couch in magnet room rather than
anteroom

Failing to adequately screen for objects on a patient that will be
affected by the magnet (keys, pens, barrettes)

Using equipment that is not designed for MRI usage (e.g., the IV pole
within the magnet room)

If items are labeled "MRI Safe" it doesn't necessarily mean they are
safe

Actions To Consider

The following actions were recommended:

Use of MRI-designated equipment within the MRI suite

Transferring patients from the stretcher to the MRI couch only in the
anteroom

Only sand bags confirmed to be MRI appropriate shall be used in the
MRI suite

A process change of having the patient disrobe prior to entering the
MRI area and putting on clothes strictly for the MRI suite. This will
prevent the inadvertent slip of forgetting about items that may pose a
danger or forgetting to adequately screen prior to entering the room.

### 

### 7. LEARNING LINKS

##### From the VA National Center for Patient Safety

We have recently come across some interesting articles and websites on
patient safety issues that we want to pass on to you.

[Academic Medicine]{.underline}

In the February issue of *Academic Medicine*, there is an article titled
"A System of Analyzing Medical Errors to Improve GME Curricula and
Programs"
([www.academicmedicine.org/cgi/content/abstract/76/2/125]{.underline}).
This is a great article about getting resident physicians involved in
RCAs. (Please note: this link is to an abstract of the article, a paid
subscription to *Academic Medicine* is required to view the entire
article.)

[The Lancet]{.underline}

*The Lancet* publishes a weekly electronic medical journal simply titled
"The Journal" (www.thelancet.com/journal). *The Journal* has a periodic
feature called "Uses of Error" in the Editorial and Review section. In
the March 3rd issue, "Uses of Error" featured an article titled "Missed
Opportunities"
([www.thelancet.com/journal/vol357/iss9257/full/llan.357.9257.editorial_and_review.15401.1]{.underline})
that deals with systems determining whether routine things get done or
not. (Please note: a free registration process must be completed before
you are able to access *The Lancet*.)

[FDA Medical Device Checklist]{.underline}

On the U.S. Food and Drug Administration's (FDA) website
([www.fda.gov]{.underline}), their Center for Devices and Radiological
Health has a useful checklist for choosing a medical device that is best
for the patient. You can find that checklist at
[www.fda.gov/cdrh/useerror/you_choose_checklist.html]{.underline}.