Keeping patients safe during medical gas works

The constant push for more highly qualified staff, and more advanced technology, has left the basics of patient safety open to errors and serious risks. Over the past two years there have been a number of incidents reported of patients being connected to medical gas pipelines during shutdowns where the designed gases have been isolated. The last incident was highlighted by the Quality Control North West (QCNW) group in October 2012. Two patients were found connected to a pipeline system by the organisation during its testing on completion of the works being undertaken. The exact specifics and locations have been kept out of the public domain to allow anonymity for the Trust and individuals involved, but highlight some very simple, basic requirements. The resulting report states that one of QCNW’s recommendations would be to deploy ‘Do Not Use’ plugs in all occupied areas during shutdowns, ensuring that accidental connections are avoided. Equally, Area Valve Service Units (AVSUs) should be correctly labelled for the number of terminal units and areas served to ensure the safety of the patients. The writing of a method statement by the Authorised Person for the shutting off of the gases, listing the valve numbers and the number of beds affected, would enable the ‘Do Not Use’ plugs to have a greater effect, and ensure patient safety during these works. Training for Authorised Persons specific to department and ward isolations, including in permitto- work completion, is also invaluable in ensuring that Trust (and other healthcare provider) staff are up-to-date with current practices, and should ideally be undertaken as a workshop over and above the standard AP course. In summary, a return to workshop-type training, method statements, and the use of simple ‘Do not use’ plugs, will eliminate the risk of serious injury to patients during medical gas pipeline works.

Rob McCrea
AE AP CP QC MGPS MIHEEM