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AirGuard
AirGuard can be fitted to air flowmeters to provide a clearly marked physical barrier that can be swung aside to allow for connection of air tubing.
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Kit |
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The AirGuard attaches to an air flowmeter to provide:
Gas misconnection is reduced by requiring a conscious decision with two-handed action to attach tubing to the medical air outlet. Oxygen is left unchanged and is freely accessible.
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Air and oxygen misconnection
Hazard ReportsJCAHO Sentinel Event Alert, July 2001
US Department of Defense Patient Safety Center Alert, March 2005 Medical Gas Sentinel Event
Veterans Health Administration Patient Safety Advisory, March 2002 Confusion between oxygen and compressed air wall outlet
NHS National Patient Safety Agency Patient Safety Bulletin, April 2007 Administration of oxygen...or is it air?
NHS National Patient Safety Agency Rapid Response Report, Sept 2009
Canadian Safety Alert Biomedical Safety & Standards, July 1991 Patient Receives Air instead of Oxygen
SA Department of Health Advisory, Nov 2006 Confusion between Oxygen and Medical Air
PublicationsOthers have reported that same problem:
Air and oxygen flowmeter confusion. Wheeler DW, Patten M. J R Soc Med 2008: 101: 526-527 (No abstract at PubMed)
Air-oxygen flowmeter confusion. Waite A, Macartney I. Anaesthesia. 2003 Feb;58(2):194-5. (No abstract at PubMed).
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Trial
The AirGuard was developed by Flinders Biomedical Engineering. AirGuards were first installed on all 276 air flowmeters at the Flinders Medical Centre in July 2007. A trial monitored incidents with use of air and use of the AirGuard; there have been no reported incidents so far (Jun 2008). Trials are also being undertaken at 2 other hospitals.
Publications
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AirGuard kit
The AirGuard kit consists of one disk and one labelled swing. The disk is specific to the air flowmeter so the indexing pins ensure the label always faces the front.
The swing hangs freely from the disk. Adhesive is used on the threaded adapter to lock the disk and swing into place. This ensures the correct color adapter is kept on the air flowmeter.
One AirGuard kit contais a disk and a labelled swing. The disk must be ordered for the air flowmeter in use. The swing label conforms to regulations in each country.
Fitting is simple: unscrew outlet nozzle, fit disk to outlet, screw nozzle back up to hold in place. Loctite may be used if required. The swing is kept facing forward by indexing pins on the disk.
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Cost
Air Guard Information Flier (pdf 163kb)
Fitting
It is suggested that the AirGuard kit be fitted by clinical engineering or biomedical engineering but this is not essential. It provides a good opportunity to audit flowmeters, and for non-standard units to be removed and replaced.
Fitting is simple: unscrew outlet nozzle, fit disk to outlet, screw nozzle back up to hold in place. Loctite may be used if required. The swing is kept facing forward by indexing pins on the disk.
Quantity
A 400 bed hospital with 360 air outlets uses 300 air flowmeters thus needs 300 AirGuards.
It is likely that 5% more AirGuards will be needed in the 12 months after installation as air flowmeters are discovered attached to equipment stored in draws and cupboards. |
Reduce air and oxygen misconnections
Use AirGuards to improve
patient safety
Use an AirGuard on all
air flowmeters.
Air Guard Information
Flier (pdf 163kb)
In a 400 bed hospital, AirGuards can be installed for about the cost of 1 patient day in ICU.
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The AirGuard is manufactured from non-brittle material. Both AirGuard and label are easy to clean (alcohol proof) and durable. |
Copyright FBE Pty Ltd, 2008 |
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