Medical Gas Safety Management: Evidence based Risk Intervention Study of HMA Gold Award Project at Vietnamese Hospital

Background: Safety of medical gas management is challenging issue in emerging countries like Vietnam, India, Bangladesh and Sri Lanka. No medical gas complies with the international system for colour coding gas cylinders. Cylinders are often the same colour regardless of the contents and the labelling is often a poor quality and inconsistent. Because of this, there is a risk of the wrong cylinder being delivered accidentally to healthcare facilities. Poorly trained staff are not aware of the importance of ensuring the correct tanks are connected to the right lines and there is not a universal system of compatibility of fittings for each type of medical gas. Hence, there is a high change of wrong gas induction to the patient and a high chance of sentinel event that leads to permanent injury or even death. Methods: In Vietnam, none of these safeguards are in place. As a result, Hanh Phuc International Hospital, as part of its risk management activities, identified issues with medical gases as a high risk area. The hospital used Failure Mode Effect Analysis (FMEA) risk assessment tool to determine the risk score of medical gas safety practice in the hospital. Results: The first FMEA score reflected (648 to 749/1000) that the medical gas safety is a high risk practice in the hospital. After intervention with colour code system, the risk reduced (120-60/1000) at minimal level. Also, the rate of compliance with medical gas safety protocols improved from 40 % in the first audit in Jan 2017 to 94 % in Feb 2017 after improvement. This rate of compliance has been sustained from the start of the project up to the present with many months showing 100 % compliance. Conclusions: The cost of the total project was less than dollars but return of impact is very significant. Although there has been no direct serious incidents reported due to medical gas injury, the FMEA indicated that there was a possibility of such an incident. The project win the Gold award after competing with 451 award entries from 123 hospitals in 18 countries at the Hospital management Asia conference, 2018 Thailand. This project has great applicability to other hospitals in developing countries that do not have strict controls over medical gases.