Not Settling for Empty Promises From Gas Cylinder Vendors
In a gastroenterology procedural center, a cart is used to integrate equipment for endoscopies and colonoscopies, including large (size E) carbon dioxide cylinders used for insufflation to reduce pain and discomfort during colonoscopies. The tanks are switched out when empty and are often changed between cases, but sometimes they must be replaced during a case. Each CO2 tank is delivered in a plastic bag with a rubber band closure, a tag that reads “full,” and a seal over the valve.
In June 2022, a gastrointestinal (GI) tech grabbed a CO2 tank from the full rack that was both bagged and tagged, but when the tank was hooked up to the insufflator equipment, they discovered it was empty. Had this tank needed to be changed during a procedure, it would have put the patient at risk. The center reported the event to the vendor and returned the tank for investigation. One month later, the vendor reported they could not determine whether the tank was leaking but had replaced the valve.
On four more occasions over the next six months, a tank packaged as full was empty when brought into the procedure room. The vendor questioned whether the staff was comingling tanks and offered more signage.
In January 2023, the nurse manager reported the empty tank issues to the center’s patient safety committee. The committee asked for investigative reports. In March 2023, the facility management company, a separate entity that orders and manages tanks at the center, found tanks in the full rack that had been delivered in open bags with no seal. When tested, the tanks were full, although the open bags and lack of a seal suggested they were empty.
The vendor created a new process in which tanks would be filled, sealed, and tagged as full in an obvious manner, and drivers were to ensure full tanks remained wrapped on delivery. Despite these efforts, in July 2023 a tank marked full was empty when hooked up in the procedure room. On two other occasions in August 2023, tanks that should have been full were empty when staff attempted to use them. These tanks were sent to the vendor for evaluation.
In mid-September 2023, the nurse manager again reached out for vendor feedback and an improvement plan. The vendor reported a new companywide mandate where size E medical gas cylinders would no longer be shipped in bags, would be inspected after filling, and would be equipped with a built-in seal and washer to ensure proper connection. This new process was implemented to segregate full and empty cylinders on delivery.
The steadfast persistence of the nurse manager to hold the vendor accountable produced a safer process to fill, mark, and deliver CO2 tanks, and make it easy to discern with a glance whether a tank is full or used when it is brought into the procedure room.
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