Minimizing misconnections to Medical Air Submitted by Name: Mark McEwen, Anne-Louise Smith Affiliation: CED Collaborator National association (if exists): SMBE, Society of Medical & Biological Engineering Location: Adelaide, South Australia E-mail address for contact: anne-louise.smith@sa.gov.au

Country Estimates in Brief Please fill the statistics you can find Population Australia 24M South Australia 1.7M Population Growth Rate Australia 1.3% South Australia 0.7% Life Expectancy at Birth 80.3 male, 84.4 female Infant Mortality Rate 3/1000 live births under 1 yr Number of Health Centers in Country 747 public hospitals 612 private hospitals Total Expenditure on Health as % of GDP 9.1% Global CE / HTM Success Stories

Global CE / HTM Success Stories Country's Health Technology Program Minimizing misconnections to Medical Air The hospital Safety & Quality department had reports of patient incidents where oxygen was supposed to be provided to the patient but they got medical air instead Patients required many days in ICU to restabilise An expert panel was created with medical, nursing and biomedical engineers to investigate the root cause of the problem The panel reviewed the reported incidents, undertook a literature review, interviewed staff, visited the clinical units and audited the medical gas set up The most common error was: Reconnection to air rather than oxygen when a patient returned from a procedure or was transferring from another clinical unit 30% of the clinical units had at least one incorrect air /oxygen set up with incorrectly colored outlets; only white (oxygen) were available from stores, and no black (air) outlets January 2016 Global CE / HTM Success Stories

Country's Health Technology Program Next Steps for Success Story The hierarchy of risk mitigation was used to assess possible improvements Error proofing could not be done without a change in standards, so an error reduction strategy was used Biomedical Engineering developed a visual/physical barrier for medical air outlets, Air Guard Had to consider infection control, ability to be cleaned with alcohol, emergency use Final device fitted to medical air outlets providing a freely hanging label that needed to be moved to attach hose to medical air and left oxygen unchanged A trial was conducted to determine if incidents due to misconnection of gases were reduced and ensure no other incidents were introduced January 2016 Global CE / HTM Success Stories

Conclusions and Action Plan Improved patient outcomes, over a 2 year period Before Air Guard, 12 patients at one hospital had reported incidents being treated with medical gas (instead of oxygen) After Air Guard, 3 patients had reported incidents (one from an area that didn’t have the AirGuard) Cost for fitting out a hospital was equivalent to 1 patient day in Intensive Care The device has been made for other hospitals in Australia, Canada, USA, UK & Denmark January 2016 Global CE / HTM Success Stories