1. Wesson Building Medical Air Compressor
Failure, Replacement, and Next Steps
Emily Bonazelli
Clinical Engineer

2. Overview Wesson Building One Medical Air Compressor
Neurology and Sleep Center
Wound Care Hyperbaric Medicine
Labor and Delivery
NICU
One Medical Air Compressor

3. Medical Air Compressor Failure Event
Saturday, January 28, 2017
7:45 PM
Engineering made aware of no pressure alarms on the medical air compressor
Low air pressure alarms on 6 ventilators in NICU
All air/oxygen blenders alarm loss of air (<20 psi)
NICU called security and CE on-Call

4. Medical Air Compressor Failure Event
Saturday, January 28, 2017
8:30PM
Engineering discovers the source of the leak and restores system pressure
Ventilators reestablish air pressure
CE on-call arrives at the Wesson Building
CE on-call reaches out to Supervisors
CE Supervisors reaches out to CE Respiratory specialist
CE Supervisor reaches out to Respiratory Manager to identify possible air tanks and regulators

5. Medical Air Compressor Failure Event
Saturday, January 28, 2017
9:30PM
CE Supervisor and CE Respiratory Specialist arrive on scene
CE and NICU staff begin disconnecting all ventilators and blenders not in use to help relieve stress on compressor
Medical Air Compressor Vendor arrive on site
10:15PM
CE discuss medical air compressor with Engineering
CE reconnects ventilators and blenders to test compressor
11:30 PM
CE checks with clinical staff before heading home

6. Root Cause Analysis (RCA) Timeline Leading up to the Event
Project Title: Wesson Women and North Wing Medical Air System
Date: 01/28/2017
Event Description
On Saturday January 28th, 2017 at 7:51 PM the NICU staff observed a system air pressure alarm. Six ventilators alarmed indicating ‘Low Pressure’ and all air/oxygen blenders alarmed indicating a loss of air pressure at least 20psi less than oxygen. It was determined that there was a loss of medical air to the Wesson Women and North Wing buildings.
Timeline Leading up to the Event
Date
01/28/2017
Sequence of Events
There was an air leak in tubing connecting the compressor to the pressure gauge
The pressure gauge indicated that there was no pressure in the pump causing the system to over pressurize one compressor
The pressure gauge continued to read zero pressure in the system causing the system to turn on all three compressors
All three compressors over pressurized causing all three safety values to open in order to reduce pressure resulting in a massive air leak
The air leak caused an actual loss of pressure in the system
The loss of pressure caused the system to no longer deliver air to the air outlets throughout the Wesson Women and North Wing buildings
Investigative Team
Engineering
Clinical Engineering

7. Replacement Planning
Monday, January 30, 2017 – Thursday, February 2, 2017
Engineering, CE, and Clinical Staff worked to determine the following:
Shutdown time frame
NICU evacuation site
Amount of medical air tanks needed to sustain NICU, LDRP, and Hyperbaric through the shutdown

8. Replacement Planning Shutdown time frame NICU evacuation site
Tuesday, February 7th at 9 am
Will take about 8 hours
NICU evacuation site
Dedicated four rooms on Infants and Children's unit
Amount of medical air tanks needed to sustain NICU, LDRP, and Hyperbaric through the shutdown
Medical air tanks were ordered to set up a tank farm to back fill medical air
Location of tank farm

9. Replacement Planning Monday, February 6, 2017
CE and Clinical staff rounded in NICU to determine how many patients are on blenders and vents
CE set up four rooms on Infants and Children’s including NICU code cart
Engineering set up tank farm
Hard stops included: baby needing or on an oscillator

16. Replacement Tuesday, February 7, 2017 7:30 AM 8:00 AM 9:00 AM 2:13 PM
CE and Clinical staff rounded in NICU to determine how many patients are on blenders and vents
8:00 AM
Emergency operations center opened
9:00 AM
Shut down begins
Running of tank farm
2:13 PM
Switched to secondary tank farm
3:30 PM
Medical Air Compressor replacement installed and functioning

17. Replacement Pressure checks every 2 hours
Every step was communicated to the EOC

18. Concerns with Current State
Wesson Building usage of Medical Air
>6000 hours of runtime for all three compressors in 2 years
HOF medical air compressor has a runtime of 500 hours in 6 years
Replaced Medical Air Compressor with same model
Needed a high pressure line for hyperbaric chamber
Know single point of failure

19. Medical Air Usage
Hyperbaric chambers were replaced and no longer needed a high pressure line
1 blender at every bedside in NICU
1-2 blenders in every LDRP room
Blenders remain on at all times

20. Next Steps Continue to discuss blender usage in the Wesson building
Add a second Triplex compressor
Requires second medical air shutdown
Currently scheduled for the end of April

21. Questions?