Medical Gas Shut-off Causal Factors:

  1. Construction project lead was trying to take advantage of what appeared to be an opportunity to work ahead; he communicated the change in plans with the PACU and ED manager assuming these were the only affected departments:
  2. The construction project lead was not fully aware of the affected areas prior to performing the shutdown; no lines were traced and facility drawings were believed to be inaccurate.
  3. The construction project lead did not communicate with a clinical leader who knew the implications for all departments.
  1. The need for oxygen shutdown had not been discussed during the weekly construction meeting and the required form for adding the oxygen shut off request had not been submitted.
  1. The facilities department was aware of the hot work permit request; however it was not aware of plans to shut off the oxygen. The request to shut off the oxygen was not part of the original hot work permit.

Hospital Renovation Tips to Assure Patient and Staff Safety

  1. Hospital leaders and construction crew must work together to assure the safety of patients, visitors, and staff.
  1. Renovation projects, regardless of size, require consistent leadership presence during all phases of construction.
  1. Use pre-construction risk assessment form. Example:
  1. Assess building(s) and ensure gas routes are properly labelled.
  1. Standardize “hot work permit” process and ensure it is understood by leadership, managers and vendors. Require multi-disciplinary team to sign off on all permits.
  1. Limit who shuts off gas (not a contractor). Consider best time of day to turn off gases for construction. Test before actually doing turn-off.
  1. Consistent and ongoing communication is key between hospital administration, clinical leaders including front-line managers, and construction leaders. Consider using computer for checklists and consistent messaging.
  1. Consider daily huddles that include an executive representative, clinical leaders, and construction leader to discuss projects for the day to assure all affected areas are considered and aware of what is occurring.
  1. Changes to construction plans, no matter how seemingly minor, should be communicated prior to implementation. One person cannot fully know the organization-wide implications for the plan change.
  1. Communication about construction progress is also important for staff, patients, and visitors to assure staff and patient safety as well as satisfaction is considered.
  1. Assume there will be emergencies and plan for them. Make sure construction and hospital staff knows who to contact when an emergency occurs. Incorporate education re: location of shut-off valves into emergency drills to increase awareness.

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