A dangerous mistake by the Hadassah Hospital staff ended in a miracle, without a disaster. A child who was hospitalized in an intensive care unit was accidentally poisoned with helium gas, which was given instead of oxygen. The mistake was quickly discovered by a nurse in the unit and the boy was not harmed.

According to the report in Yisrael Hayom, the incident occurred at the end of 2017. During the evening shift, a hospital employee was asked to supply a cylinder of Liquefied gas – a mixture of helium and oxygen. The worker accidentally brought in a cylinder of helium and connected it to the child’s regulator. Helium gas alone without oxygen could be dangerous if the child was breathing from it alone without breathing at all from the room air it would cause disaster.

A senior anesthesiologist, explained to Yisrael Hayom that “if the child breathed in air that was in the room and if it was for a very short period of time then there is no harm to the patient.”

The case was reported to the Ministry of Health and will be investigated by the Department for the Safety of Treatment. An examination conducted by the Ministry of Health found that the volume of the gas cylinders is the same and their marking color is similar (the helium is brown and the color of the mixture with oxygen is brown and white), which can lead to potential errors.

It was also found that the error was caused because a procedure was not performed to identify the gas type before it was given to the child. In addition, there are no written procedures regarding the treatment of medical gases among some of the employees. The committee recommended physical separation between the gas types in the hospital’s warehouse and training for the workers handling the issue, in particular the proper identification of tanks containing gases.

“The hospital director appointed a control and quality committee that studied the subject, a problem at the national level regarding the labeling of helium and heliox (helium and oxygen).

“As a result, the Ministry of Health has set up a committee to examine the issue in a broad manner in Israel, and in order to prevent recurrence of such cases in the future. there has been a change in the fashion the gases are handled in Hadassah, as heliox is now totally separated from helium. Regarding the child in this case, hospital officials stress since the child was being monitored in an ICU, continuously, there was no life-threatening situation at any moment,” Hadassah said.

The Ministry of Health said: “The Safety Department promotes knowledge sharing among the medical institutions in order to raise the awareness of the medical institutions regarding the risks and possible failures in the provision of medical gas, while recommending the prevention of the next event.

(YWN Israel Desk – Jerusalem)