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Near misses matter

Posted Jan 23 2009 3:57pm

A story published on our hospital intranet from our BIDMC SPIRIT group, with the aim of spreading this kind of discovery to other areas:

The recent case of an exploding light bulb and near miss injury in the Neonatal Intensive Care Unit (NICU) serve as a good example of the kind of quick, positive change that can happen when near miss incidents are treated as serious safety threats.

Last month, NICU nurse Sarah O’Neil, RN, was using a250-watt warming light to prepare an infant scale for weighing a newborn patient when she heard a loud “POP!” – as if something exploded. “I turned around and saw a small flash, and then smoke was rising out of the top of the warming light,” she said. “The flash and smoke extinguished within seconds. Then I noticed there were small shards of glass all over the top of the scale, and a small amount on myself.” Neither the patient nor O’Neil was injured by the incident. “It scared me to know that the patient and I could have been affected much differently had the incident happened minutes later,” said O’Neil.

After unplugging the equipment and securing the area, O’Neil filled out an incident report that immediately triggered the involvement of Rich Stroshane, Product Recall Technology Coordinator; Steve Fairbrother, Biomedical Technician 3, and Cecil John, Biomedical Technician 2, from Clinical Engineering; Mary Ward, Health Care Quality; and Gary Schweon, Director, Environmental Health and Safety.

“When we went and looked at this warming light, we decided to look at all the other warming lights in use on the units,” said Schweon. “For safety, all of the lights have protective screens in front of the bulbs. This was intact in this case. We surmised that the glass shards came out the top of the lamp housing. “What we also noticed was that the bulb that exploded and all the other bulbs, except for one, looked the same. One bulb looked very different from the others – it had plastic-type sheathing around the bulb.”

Turns out that this was the only Teflon-covered shatter-proof light bulb in the 12 warming lights in use throughout L&D and NICU. Unfortunately, the bulb that shattered, as well as all the others – except one – was a regular bulb. Since there was no protective coating on the bulb that blew, it had not prevented glass shards from exploding outward and upward, he said. “At that point we pulled all the lamps out of service until we could get the newer shatter-proof bulbs, which we did within 12 hours," said Schweon.

Searching for a root cause, the group’s focus quickly turned from light bulbs to warmers. “I never thought of these bulbs as being a potential danger, but some of these warmers are pretty old,” said Jane Smallcomb, RN, Nurse Manager, NICU. “I’ve been here 16 years and they were here when I got here.” Schweon believes that at the time of purchase, shatter-proof bulbs had not been invented and not identified in the user manual.

The team reached out to senior leadership, presented the problem as an urgent need, and is seeking funds to purchase new warming lights to replace the older models. In the interim, the oldest warmers have been removed from service and all warmers in use have had shatter-proof bulbs installed, said Smallcomb.

“I have to say the scariest part about what happened was the possibility that five minutes later a baby would have been lying on that scale,” said O’Neil. “I’m just so thankful that the patient was not harmed in this situation. I’m also grateful that the bulbs have since been switched to a shatter-proof bulb, so that something like this is prevented from happening again. It's great to see that such quick action was taken to resolve the cause of the incident.”

Schweon says there is an important lesson all staff can learn from this incident. “We were able to take quick corrective action on something that posed a serious safety risk to both patients and employees, but only because someone treated a near miss as a reportable incident,” said Schweon. “NICU Nurse Sarah O’Neil gets a lot of the credit for making this happen because she saw this threat and filled out the incident report that set these wheels in motion.”

If you witness a dangerous condition relating to equipment in the course of your work, please stop and take the following actions:
1) Immediately take the equipment out of service and report the malfunction to your manager;
2) Contact the appropriate service group (Maintenance, Clinical Engineering, etc …) if known;
3) Complete the incident report;
4) Fill out a red “Equipment Management Program” tag, indicate that the device was involved in an incident and/or that an incident report was written, and sequester the device in a safe, secure location;
5) Remember that if it can happen to one piece of equipment then it’s possible it can happen to all other like pieces of equipment.
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