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PSRS
Report Forms are available at VA Facilities and at the PSRS
Website http://psrs.arc.nasa.gov
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Future
issues of FEEDBACK,
can be sent directly to you:
You
can subscribe by going online to
http://psrs.arc.nasa.gov
/contact
Or
mail your request to
PSRS
PO Box 4 Moffett Field, CA 94035-0004.
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Emergency
Situations Prompt PSRS Reports
Watch
That Spark
An anesthetist
alerted a surgeon to a dangerous situation in time to prevent a
possible fire in the operating room.
- A
patient was undergoing a tracheostomy under general anesthesia.
He was intubated receiving at least 50% oxygen through the endotracheal
tube. The surgeon had made the initial incision and had entered
the trachea causing anesthetic gases and oxygen to flow out of
the tracheostomy incision. About this time, the surgeon grabbed
the electrical cautery to cauterize a bleeding vessel at the wound
site.
At this point
the reporter intervened:
- I
immediately said, "There is a very high concentration of
oxygen coming out of the wound." As a result, the surgeon
did not cauterize the bleeding site, thus possibly averting an
explosion [fire] from the high concentration of oxygen and electrical
current.
The reporter
was concerned:
- There
is not a departmental policy/procedure that addresses this issue.
Recent case
reports support this concern:
1. Ann
Otol Rhinol Laryngol Jan 1991
2. Ann
Otolaryngol Head Neck Surg Jan 1992
3. South
Med Journal Mar 1998
4. Ann
R Coll Surg Engl Nov 2001
5. Ear
Nose Throat Journal Feb 2002
6. Acta
Anesthesiology Sin Dec 2002
Ensuring
Safer Exiting
Planning ahead
to more easily evacuate their healthcare facilities in the event
of an emergency prompted two PSRS reporters to offer suggestions.
In the first case, a veterans support group continued to meet
after a fire drill began, rather than leaving the building. Once
alerted to the need to evacuate, the elderly veterans faced some
challenges:
- [The
veterans] have many serious debilitating disabilities. Our meeting
is on 2nd floor
[where] the elevators automatically lock,
so the group helped each other [down the stairs], some with walkers
or canes, and one veteran was carried down the stairway in his
wheelchair.
The group eventually
got outside, but they reflected on their performance:
- ...
In
subsequent weeks [the veterans] pointed out how hard and slowly
it had gone. So we traded and moved to a first floor meeting room
now. I had never considered how debilitated they had gotten and
wonder if the rest of the VA system needs to be thinking about
that.
None of our group was hurt, but in an intense fire
with much smoke, I wonder how well would they have done?
The second reporter
noted:
- [We
need] to improve the safety of our patients in the event of an
emergency such as fire, explosion, tornado, attack by terrorists,
chemical or biological warfare
With all the clutter in the
hallways of carts, computer tables, serving tables or carts, wheelchairs,
medical monitors, and scales, it would be a tremendous task to
get the patients out with wheelchairs, and an impossibility removing
the patients attached to their beds and monitors, with no time
to put them in wheelchairs.
The reporter
envisions matching specific employees to specific pieces of equipment:
- Have
an employee assigned to each item clogging the halls. When the
task with this item is completed, the item would be placed into
a room or storage area out of the halls. If an emergency arises,
the item would be immediately removed from the halls by the employee
assigned to it.
Smoke
Gets in Our Eyes
Two reporters
described some hazards they observed with patients smoking. The
first reporter described a potentially fatal accident:
- The
patient in a wheelchair went to smoking room. Nursing staff heard
screaming from room, found the patient lying on the floor with
flames on chest. [An employee] used the pillow from the wheelchair
to put out the fire. Another RN put out a lighted cigarette and
then called emergency ambulance
The patient was transferred
to a burn unit at affiliated hospital.
This event prompted
changes in their "safe smoking" environment:
- Water
extinguisher (to decrease respiratory irritation when deployed)
- Fire
blanket outside of room
- Metal
furniture instead of naugahyde
- Bigger
windows in door to room to observe patient
- Removal
of flammable items in area (plastic bags)
- Enough
good, big ashtrays
They changed
some procedures as well:
- Assessment
tool used will include inquiry into safe smoking determination
and evaluation of prior smoking accidents/close calls, as well
as enlistment of family or visitors for assisting/observing smokers
in the smoking room.
The second reporter
focused on some different issues found in a psychiatric setting:
- Patients
are allowed off unit to smoke after they have been here 72 hours,
and are deemed no harm to self or others. We have
scheduled smoke/off ward times
We have had several small
fires in the past one patient was burned... it is impossible
to police our clients when they are off ward. Not enough staff
to escort them.
The reporter
predicted another undesirable consequence:
- Patients
come up en mass to get cigarettes and lighters, which are kept
in nurses station
the same area meds are administered.
There is almost always lots of clamoring and demands for staff
to hurry and sign them out for a smoke. There is a
potential for making med error, due to the congestion.
For
Want of an IV Bag Label
Not knowing
that an IV bag contained an additive is a problem, according to
a PSRS reporter:
- [I]
took a 500 cc normal saline bag from the unit refrigerator and
almost hung it for bolusing a hypotensive fresh postop patient
[and] found a sticker label that had fallen off the bag that said
heparin was added.
The reporter
asked for more secure labeling:
- IV
bags with heparin in D5W come marked (red markings on the IV bag)
from the pharmacy. If a heparin solution needs to be in normal
saline, a white peel-on label is placed on the IV bag. If the
label comes off there is no way to identify that there is heparin
in the bag
Any bag with heparin should have markings on
it that can not come off.
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