Lecture 18 Case Study: Misuse of oxygen concentrators Human Factors Lecture 18 Case Study: Misuse of oxygen concentrators

Company A’s product: Company A’s description of their product. Approx. one-million people are put on LTOT due to diseases such as COPD. These are pictures of the company's oxygen concentrator products. Medical oxygen is used for patients with diseases such as COPD, to help them breathe. These are pictures and descriptions taken right off of their website. No where in the description online, or on the website at all, did it have any warnings about the product’s dangers. Company A’s description of their product.

Burn Case: March 2010 Decedent was smoking in vicinity of oxygen concentrator of Company A Cannula caught on fire, severely burning the decedent Decedent later died due to injuries Lawyers blame equipment failure, and warning negligence Start by explaining case, state that company knew of dangers (FMEA reports…) but did nothing about it to change products so these tragedies would stop happening. What went wrong? Who’s to blame? How can this change? > questions to ask class about. Image of cannula tubing burning from smoking near oxygen concentrator.

Burn Case: March 2010 Oxygen concentrator placed in home registered 8,020 hours of previous service The device was made in 2006 and placed in decedent’s home in 2009 (accident happened in 2010) Investigators claimed the device was defective and the company was at fault

As you can see, smoking materials account for 73% of medical-oxygen related burns. 30% of patients who receive this type of therapy continue to smoke. Not all of these cases are due to company a’s product, but this stat shows that medical-oxygen related burns is an epidemic in the country. Give statistics: 182 home fires, 46 fatalities, 1,190 burns, 89% facial burns each year due to oxygen-related burns.

The Hazard Control Hierarchy A useful framework in order to avoid hazards 1. Design Designing the hazard(s) out of the product completely. 2. Guarding Placing barriers to separate people from the hazard 3. Warning If selected, should be well-designed in content and format Designing the hazards completely out of the product is the best possible strategy in preventing any unintended consequences from taking place. Guarding is the next best option. Warning is only effective if thoroughly tested before use. By applying this type of human factors to the product, it will make medical oxygen safer for all users. But how do we do that?

Designing Hazards Out

Insert fire breaks here Using Fire Breaks Fire breaks are a secondary prevention for fires They do not prevent fires! Inserting small piece of plastic, to act as a gas shut off in tubing when activated Cuts off oxygen supply, taking away the fire’s fuel Easily inserted into new products and products already in homes Inserting fire break near the nose inserts on the cannula will help keep the flames from reaching the oxygen concentrator (if fire breaks out near face), avoiding lots of damage. If the flames were to surpass this fire break, adding one where the cannula meets with the oxygen supply would also stop the flow of oxygen. Insert fire breaks here

Using nonflammable tubing Cannula made of PVC, highly flammable and toxic when burning. Cannula is usually 4-7ft long Making entire cannula out of nonflammable material would prevent fires Even adding small pieces of nonflammable material could make the cannula safer Would be expensive to design and produce Adding nonflammable pieces to the nose inserts on the cannula and near where the tubing connects to the oxygen supply would help stop patients faces from burns and prevent fire the make its way back to the large supply of oxygen.

**Warnings**

Is this a good warning? This is my drawing of the warning label depicted on the back of the oxygen-concentrator from the 2010 case. It is not very well designed. First of all, the warning being on the back of the machine where no one looks is a bad design. This warning does not convey any serious danger and should be redesigned. The ‘warning’ symbol should be bigger and there should be a picture depicting the dangers of having an open flame near the equipment. The company should take necessary steps to designing a new warning.

What makes a good warning? The ANSI designs warnings for products and facilities American National Standards Institute Keeps a standard for warnings All easy to understand Universal Simple but effective This warning is clear and concise. If seen on or near equipment any user who can read English will know not to smoke or have open flames around. By having a standard for all warnings it makes them clearer for everyone, nationwide to understand.

Some examples of ANSI’s warnings… All of these warnings relate to oxygen, and having an open flame around any oxygen container. Any of these warnings or a combination of them would have been useful to put visibly on the oxygen concentrator instead of the one that was used. The equipment in the case was gray so using bright yellows and reds draws the attention of the user to read the warning. The warning should be placed directly on the front, or wherever the user will look at the most, instead of on the back of the equipment where a user is not likely to check. Have class come up with new warnings to put on oxygen concentrator.

NFPA’s Fire Safety Tips Overview Never smoke in a home where oxygen is used Post “no smoking” signs in and outside the home If oxygen is used in the home, the amount of oxygen in everything else in the home goes up, making it easier for a fire to start Never use an open flame when oxygen is in use People who have difficulty escaping a fire should have a phone near their bed or chair Make sure that the home has smoke alarms and test them monthly Have a home fire escape plan with two ways out of every room and an outside meeting place Practice escape plan twice a year. Many of these tips are helpful but they depend on the users making sure they follow through on them to protect themselves and people who enter the home. To make sure these rules are followed proper education and training of caregivers in patients homes must be implemented.

In Conclusion The goal of human factors is to make jobs, and tasks easier, safer and more effective to perform. It should be looked at as a proactive science If the ideas of human factors is utilized more efficiently, time, money and lives will be saved.