SixSigmaCase Studies

Oxygen Supply Disruption

A recent incident in Delhi Hospital which has key takeaways for Process Excellence professionals, though the situation & application might vary, depending on the Industry

Four killed due to alleged negligence in Delhi government hospital; probe ordered

New Delhi: In a case of gross medical negligence, four critically-ill patients died at a government hospital in Delhi on Tuesday, allegedly after their oxygen supply was disrupted for several minutes. The state government has now ordered an inquiry into the incident.

The oxygen supply machines at the Sushrut Trauma Centre in north Delhi allegedly malfunctioned, claiming the lives of Rajkumari, 35, Javed, 20,Rehana, 36, and a 25-year-old who is yet to be identified.

According to the First Information Report (FIR) filed by the police, there was a drop in oxygen pressure at around 2 am on Tuesday. Desperate calls to the gas plant went unanswered, forcing a doctor to rush there who got the supply of the gas resumed. But the problem recurred at around 6:45 am. This time, though, the lone helper present in the gas plant claimed that there was no drop in pressure in the supply of oxygen. He later opened another oxygen cylinder as a precautionary measure. The normal supply of the gas was restored in a within a span of around 10 minutes but the damage had already been done. The condition of the patients had deteriorated who later died. A fifth person, whose condition was stated to be serious, also died today. It is not clear, though, if he died due to the shortage of oxygen.

Note : Article courtesy : www.ndtv.com (Thank you)

Authorities at the hospital have pinned the blame on the private company which runs the oxygen supply facility there, claiming that the latter had failed to provide enough back-up cylinders to stabilize the supply.

"Hospital is innocent and not responsible in any way...the technician provided by the private contractor was not trained and he didn't respond to the drop in oxygen level...at a time, 10-12 cylinders are attached to each other but he attached one cylinder at a time," said Dr. Richa Diwan, the Medical Superintendent of the hospital.

Meanwhile, angry relatives of the victims staged a protest at the hospital.

Police have registered a case of causing death by negligence (304-A) and negligent conduct with respect to machinery (287) against the private contractor, PES Installments Private Limited. A person from the company has also been detained.

Expressing grief over the incident, Delhi Health Minister AK Walia ordered a probe by a three-member committee that has been asked to submit its report by Friday.

Mr Walia has also called for a meeting today to review the working of all government hospitals in the city. The state government has also declared a compensation of two lakhs for the deceased.

Outcome : A case study for future.

Note : Article courtesy : www.ndtv.com (Thank you)

It shows how important "Uninterrupted supply of Oxygen is" in a hospital. Equivalents exist in every other industry.

The 1st drop in Oxygen pressure instance should have raised alarm for a thorough check IMMEDIATELY. Did not happen.

The staff present at the location. Not Trained

Now, a 3 member committee to investigate An avoidable exercise : NVA

Compensation of 2 lakh could be Cost of Poor Quality. But, there is no price to "Life”

The Hospital is blaming the vendor. But, isn't it the Hospital whose reputation is lost & also is'nt it the Hospital's responsibility to ensure

that the vendor is doing his work right.

Key Takeaways :

Note : Article courtesy : www.ndtv.com (Thank you)