(IIIMS): An The Hyperbaric Incident Monitoring study International Study of Incidents Occurring in Hyperbaric Medicine Units Christy Joan Pirone BSN, Rfl Master of clinical science infulf;.ltment of the requirementfor the Degree of Thesis submitted to the University of Adetaide Adelaide UniversitY Department of Ctinical Nursing October 2000 GONTENTS Page Abstract Summary of Thesis vlll Declaration 1X Dedication x Acknowledgments xl List of Tables xiv List of Figures xv List of Abbreviations xvi 1 Introduction 2 The Research Questions 2 Aims 2 Obiectives J Overview of the thesis structure Chapter 1 Incident Monitoring In llealth Care 5 5 1.1 Scope and Significance of the Clinical Problem 7 l'2tncidentReportinginHealthcare:ReviewoftheLiterature 7 1.2.a Overviø,t¡ and Methodologl of the Revietv I 1.2.b Evolution snd methods of incident reporting 13 1.2.c IncidentAnalYsis 1l Chapter 2 History of SafetY in Clinical Hyperbaric Medicine t7 22 2.1 Hyperbaric Specific National StandardJGuidelines 22 2.2 Training Chapter 3 Review of the Literature: Incidents and safety in 27 Hyperbaric Medical Practice 28 3.1 MethodologYofthereview 29 3.2 Review of Incident Monitoring in Hyperbaric 31 3.2.a Findings of Incident Reporting in Iþperbaric 33 3.3 Incident literature review by type of incident 34 3.4 Fire úrcidents 36 3.5 Pressure Incidcnts 38 3.6 Hyperbaric StaffSafetY 38 3.6.a Fitness to dive 43 3.6.b Incidents Affecting Stqf Safety DecomPres s ion Illne s s (DC I) Barotrauma Pressure related iniuries OrygentoxicitY Mus c ulo s læl e t al Effe ct s Other 50 3.7 Patient Problerns 50 3.7.s Barotrauma Eqr Sinus Pulmonary 56 3.7.b Oxygen toxicity Central rrerv ous sY s tem P ulmo nary onY gen tox¡ c itY Tisuql side effects 59 3.7.c Hypoglycemia 60 3.7.d Confinement AraietY 6t 3.7.e Mortality lll 3.8 ChamberÆquiPmentProblems 61 Chapter 4 Research Design and Method 64 64 4.1 Research Design 65 4.2 Research SamPle 67 4.3 Research Tools 4.4 Researchprotocolsandprocedures 72 4.5 Analysis 73 76 4.6 Ethical Issues / Confidentiality 76 4.7 Strengths and Limitations of the Design Chapter 5 Results 80 82 5.1 Demographìcs 5.1.a Where the Incident Occurred 82 5.r.b I(ho/What lrrolved 83 5.1.c Age of lwolved 83 84 5.2 Types oflncident 5.2.a Patient Problems 85 Barolrauma Oxygen toxicitY P sy cholo gical re ac tions Other 5.2.b Equipment Problems 90 IIoods Buil t -in-br e athing sy st em (B lB S) Overboard duùtP sYstem (OBD) Breathing masks Monitors Ventilators Sucîion devices Other equiPment lv 95 5.2.c Chomber Problens Fire risk Ot her c hamb er inc i dent s Overboarddump Pressure problems Gas supply 5.2.d Staf Problems 98 5.2.e VentilationProblems 100 100 5.2f Tubes and Line Problems 5.2.g Drug Problems 101 to2 5.3 Na¡ratives t02 5.4 Confübuting Factors 106 5.5 Minimising Factors 106 5.6 Incident Prevention Chapter 6 I)iscussion t07 107 6.1 Demographics 110 6.2 Incident Prevention 111 6.3 Types oflncidents 111 6.3.a PatìentcomPlìcations Ear batotrauma Otlßr barotrsuma Orygentoxici| Cennal nervous sYstem Pulmonary Tisual P sycholo gic al re actiotts Other patient comPlications t2t 6,3.b EquiPnenl Problems Hoods B uilt-in-bre dhing sYstem (B I B S) Overboørd dumP sYstem (OB D) Monitors Yentilators v Fire Risk 6.3.c Chamber Problems t26 Ot her c hamber inc i dent s 6.3.d Staf Problems 128 Barotrauma Decompression illness (DCI) and CNS Arygen Toxicþ P ul mo nary orY ge n t ox i c i fY Other problems 6.3.e VentilationProblems 133 6.31 Tube and Line Problems 133 6.3.5 Pharmacological 133 133 6.4 Contributing Factors t36 6.5 Minimising factors Chapter 7 Summary and Conclusion 138 140 7.1 Strørgths / Limitations 7.2 Logisticallimitations 143 t43 7.3 Other stengths 144 7.4 Positive outcomes of the studY t45 7.5 Major Finding of the Research 7-5.a Patient Problems t46 Barotrauma OxYgen toxicitY P sy cholo gicøl re ætians Other patient comPlicatiow 7.5.b Equipment andchamber problems 147 Hoods B uil t -in-br e alhing sy s t em (B I B 8) Overboard dumP sYstems (OBDS) Vent il at i ott/Monit or s Fire risk Other C hamber Inc idents 7.5.c StaffProblems 150 7.5.d Minimisíngfactors 150 t5l 7.6 Recommendations of the StudY vl References 159 Appendix A: Types of Hyperbaric Chambers 179 Appendix B: German Hyperbaric safety Publications 181 Appendix C: Hyperbaric Safety References 182 Appendix D: Types of Guidelines, standards, and codes 183 Appendix E: Experience and Mishap Report Form 187 Appendix F: HIMS RePort Form 188 Appendix G: Bthics APProval 192 Appendix H: Hyperbaric Breathing Bquipment 193 vll Abstract Summary of Thesis units or as a consequence of This thesis analyses incidents that occurred in Hyperbaric Medicine for safety hyperbaric oxygen exposufe with the aim of developing recommendations care literature demonstrates improvement in hyperbaric medical practice. Analysis of the health into its causes through the use that medical error is of significant concern and that investigation method for safety of ..neal miss,, anonymous voluntary incident reporting is an effective that the systematic collection of improvement. Reviçw of the hyperbaric literature demonstrated involving morbidity or incidents was limited to retrospective anecdotal reports, mainly those has not previously been mortality and that a comprehensive review of hyperbaric safety issues that have been reported in conducted. This study presents a comprehensive review of incidents from a convenience the hyperbaric literature and data from 200 reports of incidents collected for a 20 month period' The sample of 45 Hyperbaric Medicine Units representing 17 countries minimised the incident and reports provided information on factors that contributed to and An integral feature of the allowed the reporter to give a narrative description of the incident. for the study participants' study design was a structured education and data feedback system the associations The data was analysed by classiffing the incidents, statistically reviewing and minimising factors and between incidents and contributing factors, reviewing the narratives with current relating them to clinical experience and the hyperbaric literature. Consistent most frequently reported hyperbaric literature, this study showed that eat barotrauma is the reported complication patient complication of hyperbaric treatment. The second most frequently literature included' is oxygen toxicity. Complications not previously identified in the hyperbaric seizure, oxygen hood deflation' stress reactions in patients having witnessed an oxygen toxicity exercises in the chamber, the aggressive patient in the chamber, risks associated with training of hyperopia, and forceful ejection of a monoplace chamber plug, vision loss in the form recommendations for pulmonary oxygen toxicity in staff. From the datA the study presents and equipment quality improvement, research, policy and procedure development, education' recommended with suggestions design modification. The continuation of the HIMS research is for improving the studY. vlll Declaration of any This work contains no material which has been accepted for the award and, to other degree or diploma in any university or other tertiary institution published best of my knowledge and belief, contains no material previously the in or written by another person, except where due reference has been made the text. I give consent to this copy of my thesis, when deposited in the Universify Library, being available for loan and photocopying' Signed Date: lx Dedication colleagues who have suffered injury or This research thesis is dedicated to fellow hyperbaric medicine, and especially to Ber¡ my have died as a consequence of their work in hyperbaric injury and continue to work in hyperbaric friend who has shown great courage to overcome his decompression illness)' Mary Ann' and nursing. Joyce Vause (deceased as a result of attendant have inspired me to strive for the the nurses who perished in the Galeazzi chamber fue hyperbaric attendants' improvement of occupational health and safety for or died as a result of hyperbaric Tribute is extended to those patients who have suf[ered treatment. have been involved in these incidents and live Remembered too are hyperbaric clinicians who 'the last link" in the chain of events or with the consequences of them, mÍrny of whom were particular day. system efïors that culminated in an incident on a not be forgotten but branded in our minds and The tragedy encountered by these people should that we do' inspire us to put safety first in the special work X Acknowledgments my parents who have supported This study has evolved as a result of several influences. First, instilled in me the ethics'to always do your me, promoted the advancement of my education and your possessiOns but no one can ever take best whatever you set out to do" and "you can lose away what you have learnt". safe care and a safe environment to my Second is my professional duty of care to provide a position to have myself caused patients. My role as a nurse and supervisor has put me in for those who are the victims of medical medical err, counselled others who have erred, and cared EITOT of Clinical Nursing' Third, is the promotion of nursing research from the Department who suggested that I formalise my Particularly, I would like thank Professor Alan Pearson my supefvisor' who has demonstrated research into Masters Degree study and Mary Fitzgerald, to research and write' enduring patience and compassion as I humbly learn interests' Dr' Bob webb first Key individuals were responsible for directing my fesearch and has been a firm supporter of my introduced me to the concept of voruntary incident reporting me the concepts of incident reporting work.