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Brain surgery patient not harmed by incompetence driven blackout

By johnboy - 5 June 2012 13

The ABC has the happy news that a brain surgery patient has survived a deliberately induced blackout during their surgery after equipment was plugged into non-backed up powerpoints during a blackout test.

Freedom of Information documents obtained by the ABC, show a power blackout interrupted brain surgery in October last year causing computers and other electrical equipment in an operating theatre to malfunction.

A brain surgeon had to keep operating without computer guidance while staff scrambled to fix the problem.

It happened during a routine generator test because equipment was not connected to back-up power.

ACT Health chief executive Peggy Brown says the problem has been fixed.

Well that’s allright then.

No, wait, it’s not. Because there’s two points of failure here and even resilient systems can get very, very dangerous when that’s allowed to happen.

Testing backup power is useful and important, but perhaps scheduling it for not actually in the middle of surgery might be considered sensible?

And then there’s plugging critical systems into non-backed up power. Just how long has that been going on?

What’s Your opinion?


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13 Responses to
Brain surgery patient not harmed by incompetence driven blackout
thatsnotme 10:25 pm 06 Jun 12

johnboy said :

I find it hard to believe they couldn’t have found a moment in the working day when they weren’t in the middle of surgery.

And if that was too hard at least have someone competent check the points before crashing the theatre

Without knowing what actually happened here, or the testing procedures the hospital uses, I can only imagine that this test isn’t the first they’ve carried out while surgery is happening. I’d hope that the hospital carries out tests like this fairly regularly, and that incidents like this haven’t happened during testing in the past.

As for someone competent checking the points…I’d have thought that a team heading in to do brain surgery should qualify? If anything good can come out of this debacle (aside from the fact that the patient wasn’t harmed, which is an obvious plus!) it should be that the hospital’s procedures are tightened up to avoid essential equipment being plugged into non-backed up power in the future. It can’t be that hard. If a pilot has to run through a checklist before taking each routine flight, I’d damn well hope that something similar happens before anyone undergoes brain surgery, or any other surgery for that matter. ‘Is all your equipment plugged into the red power points’ shouldn’t be a really hard addition to any checklist. And if it’s already there, then someone deserves to have their arse kicked.

wildturkeycanoe 10:11 pm 06 Jun 12

johnboy said :

I find it hard to believe they couldn’t have found a moment in the working day when they weren’t in the middle of surgery.

And if that was too hard at least have someone competent check the points before crashing the theatre

First part – is there a moment in any part of the day when they aren’t doing surgery???[Apart from elective of course]
Second part – power points or contact points?? Only kidding, yes the equipment should be plugged in the right place and even the staff should realise after a moment that it should have started up again when the lights turned back on. Then it would only take a genius to work it out.

screaming banshee 10:06 pm 06 Jun 12

At best there would be a generating plant per building but more than likely they have only one or two generating plant across the whole site. Could you imagine how difficult it would be to find a time or confirm that no theatres are operating.

Perhaps they should have someone competent check the points before crashing using the theatre

johnboy 9:55 pm 06 Jun 12

I find it hard to believe they couldn’t have found a moment in the working day when they weren’t in the middle of surgery.

And if that was too hard at least have someone competent check the points before crashing the theatre

screaming banshee 9:51 pm 06 Jun 12

Sure, if you want a worthless test that makes the people with no idea feel like they are doing what they need to to prove everything is hunky dory.

Many sites have fallen fowl of testing the generator starts and runs without load only to find when the power actually fails that the load isn’t transferred to the generator courtesy of a failed component in a switchboard.

If you do test it properly and the system fails you can turn mains back on and address the issue with minimal interruption, if you only find out when the mains actually fails then hopefully you brought a paddle.

HenryBG 10:04 pm 05 Jun 12

screaming banshee said :

A couple of points
– the best time to test something is when it is being used, if you test it in the middle of the night it’s not a proper test
– testing the generator does not prove it will work, it only proves it would have worked
– if the power had actually failed they would be in the same or worse position

The fact these guys test under real conditions regularly is to be admired, the fault here lies with the equipment being plugged in to the wrong outlets. If the regular testing was at fault there would be cases like this every couple of weeks.

I hear what you’re saying, but my understanding is that the purpose of the generator test is to ensure the fuel is OK and the generator actually works, not so much to test the power infrastructure.

screaming banshee 7:26 pm 05 Jun 12

A couple of points
– the best time to test something is when it is being used, if you test it in the middle of the night it’s not a proper test
– testing the generator does not prove it will work, it only proves it would have worked
– if the power had actually failed they would be in the same or worse position

The fact these guys test under real conditions regularly is to be admired, the fault here lies with the equipment being plugged in to the wrong outlets. If the regular testing was at fault there would be cases like this every couple of weeks.

HenryBG 3:03 pm 05 Jun 12

I used to work in a hospital and the generator testing used to drive me nuts. It was done in-hours at 9am once or twice a month.

How much easier would it be to schedule these for out-of-hours?

Jivrashia 12:24 pm 05 Jun 12

Without pointing blame at anyone, let’s just admit it:

IT WAS ONE BIG F**** UP.

Okay, now that that’s out of the way let’s revise this generator test as well as procedures for ensuring outlets with backup powers are being properly utilised.

Or… is there a more deep seated problem at Canberra hospital other than a simple oversight?

poetix 12:06 pm 05 Jun 12

Unnecessary pressure on the brain surgeon. Unbelievable. What’s he (?) supposed to do, rig up the computer to a lightning rod and hope for a storm so he can see what he’s doing on the screen? He must have a very cool head indeed to be able to assimilate the computer failure and keep going. Fortunately the patient’s head wasn’t made a little too cool by the whole thing.

wildturkeycanoe 11:19 am 05 Jun 12

Okay folks, we will hold off all important surgery during the hours of xx:xx pm and yy:yy am on the DD/MM/YYYY to conduct a backup generator test. I just hope that the entire A.C.T region is informed of this event, so that they can postpone motor vehicle crashes, armed police confrontations, industrial accidents and other traumatic misfortunes.
Some surgeries can go on for 12 hours, do you honestly expect the maintenance crew to show up after hours, day after day, just to be told “Sorry, there’s an important procedure taking place, you’ll have to come back again next week.”? Eventually there will be a legitimate blackout and the backup equipment fails due to lack of maintenance and testing. Then the patient is in real strife because the technicians are at least 30 minutes away and don’t have flashing lights on their vehicles.
The mix up of using non-essential power outlets for surgical equipment is a greater concern and one they should investigate thoroughly. Red means essential, white means for your mobile phone charger or electric shaver.

p1 10:44 am 05 Jun 12

Testing backup power is useful and important, but perhaps scheduling it for not actually in the middle of surgery might be considered sensible?

Testing backup systems is an important thing to do occasionally. It lets you find out if your generators work. And, as in this case, it lets you find out if your appliances are actually plugged into the right power points.

However, crash testing of cars, planes, etc is not done with live passengers on board. Like wise, crash testing operating rooms really shouldn’t be done with live patients on the table.

It’s not brain surgery people!!!!

{{ohhh, wait….}}}

sneakers 10:25 am 05 Jun 12

Agreed. Not cool. Scheduling should be the first step in any contingency plan.

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