Monoplace Delivery System
Monthly Hyperbaric Safety Notice: October 2005
Complacency and Checklists
Background
Checklists for equipment or people form the very basis for the safe application of any process or intervention. Failing to ensure that operating parameters are correctly set may result in malfunction. Resulting malfunction may be a simple annoyance. It may be fatal. A recent case in point is the August 2005 loss of a Cypriot Boeing 737 airliner, killing 121 people. The pre-flight checklist requires a manual check of the position of the pressurization valve. It was set correctly when the aircraft was parked overnight by the crew who would fly it again in the morning. However, maintenance crews operated the valve overnight and left it in the incorrect position. The following morning the pilots failed to follow their required checklist and did not check the position of the pressurization valve; complacency? A fundamental failure in safety procedures and this simple act of omission resulted in enormous loss of life. The aircraft took off, flew up to 33,000 feet, a point beyond the ability to maintain consciousness. With the crew and most of the passengers unconscious, it flew on until it ran out of fuel.
The Issue
What can we learn from this tragic loss? Reported hyperbaric incidents suggest that complacency is alive and well in our medical specialty; a specialty that poses a particularly unique risk given the pressures and oxygen concentrations in use. Incidents may be as benign as a failure to check that the audio communication charger is plugged into a power supply at the start of the day. Resultant loss of patient communications is alarming but rarely harmful. Why was it not checked? Well, it was okay at the end of the previous day, and the same staff was scheduled for the following day. Unbeknownst to the staff, a housekeeper visited during the night and a mopping behind the chamber disconnected the power supply.
It may be as dangerous as failing to analyze the percentage of oxygen being delivered. A nurse died in Florida because she was decompressed breathing air instead of oxygen after attending a case of decompression sickness at 6.0 ATA in a multiplace chamber. A similar incident in California paralyzed a hyperbaric nurse. Patients have been given oxygen instead of air during ‘air breaks’ in monoplace chambers. Patients have been compressed on the incorrect gas (air instead of oxygen, oxygen instead of air). Complacency or inexperience contributed to each of these incidents.
Bottom Line
Several checklists have been incorporated into NBS practice requirements. They address clinical operations, patient care and equipment upkeep. As with the operation of a Boeing aircraft, they are mandatory. As with the Cypriot airliner, they are occasionally not completed in their entirety. This Safety Notice, then, serves as a reminder that checklists are critical to the safe and effective operation of the hyperbaric medicine program. They allow for a comprehensive patient and systems review and remain one of the more critical aspects of your hyperbaric duties. If you are unsure about why certain items are listed, what you are checking for or question the requirement, don’t just initial it off and/or disregard it. Ask either your Nurse Manager, Safety Director or Corporate Operations Director for clarification so you understand it and become a better teacher for the next staff member.
Contributing Author: Dick Clarke, CHT
Dick
is President of National Baromedical Services, which he founded in 1986. His
previous background included service in the British Royal Navy, diving instructor
and underwater photographer, assistant director of the seabed habitat 'HydroLab'
and several years in the offshore commercial diving industry. Dick heads the
Baromedical Research Foundation where he serves as Principal Investigator for
several international clinical trials. He is course director for 'Primary Training
in Hyperbaric Medicine' and the 'HBO 2000' series of advanced hyperbaric symposia.
Dick has been a NOAA Diving Medical Officer Training Course faculty member since
1983. He pioneered the Certification in Hyperbaric Technology (CHT) program,
is a past president of the National Board of Diving and Hyperbaric Medical Technology
and remains active at the committee level within the Undersea and Hyperbaric
Medical Society.
Full Panel of Safety and Technical Correspondents
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