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The power failure at Karolinska University Hospital, Huddinge 7 April, 2007 – KAMEDO-report 93

The Kamedo-reports are published by the Swedish Disaster Medicine Study Organisation (Kamedo), at the National Board of Health and Welfare. Observers study the medical, psychological, organisational and social aspects of disasters. The results, with a focus on experiences gained, are presented in the reports.

 

Summary

A sudden and extensive power failure occurred at Karolinska University Hospital in Huddinge on Easter Saturday, 7 April 2007, at 12.13 pm. An earth fault in a high-voltage cable connecting two substations in the hospital knocked out 70 percent of its electric power supply. The fault automatically tripped circuit breakers in switchgear and the connection between the substations was broken. The substation that supplied power to most of the hospital was consequently not live. The second substation was still connected to the external power network and was able to supply the hospital’s main building with electric power throughout. The main building contains emergency rooms, radiology, a pharmacy, shops, a café, areas for visitors and the hospital’s control centre. The power failure lasted one hour and 22 minutes, but it took a long time for activities to return to normal.

The power failure meant that many patients were at great risk, particularly in the intensive care unit and other departments where critically ill patients were being cared for. However, no patient was harmed, which is principally due to the fact that the power failure occurred at the weekend – in the middle of the day – when no major surgical procedures were under way and that no major operations had been performed on the days leading up to the long weekend. Resolute action on the part of management and staff also contributed to the favourable outcome. The managers ordered staff from the morning shift to stay on while replacement staff were arriving, leading to extra staff being available to monitor worried and care-demanding patients.

The power failure meant that many items of medical equipment critical to patient safety did not work. Rooms lacking daylight and with no emergency lighting were completed blacked out. The patients’ signalling system to summon assistance stopped working. It was not possible to open medicine cabinets, changing rooms and other rooms with combination locks. The staff had to call security to open a medicine cabinet, and in another department staff smashed a window in order to gain access to necessary medication. Nearly all the lifts stopped and food supplies were delayed.

The pressure in the central pipe system for respiratory air fell after the compressors stopped working despite one of the three compressors having a power supply. This was due to faulty design of the control of the compressors and their cooling system. Staff had to connect reserve gas cylinders instead. When these ran out there was no possibility of getting hold of new cylinders. In the Department of Surgery it was not possible to connect cylinders of respiratory air. This meant that the staff could not use surgical and secretion aspirators.

Preparations for two urgent operations were discontinued and the patients were sent back to their wards. In addition, the staff had to discontinue two dialysis sessions early.

The power failure meant that all IT systems for administration and health care-support ceased to function. It was particularly critical to patient safety that the patient record system TakeCare, the patient monitoring system Clinisoft in the intensive care unit and the operative planning system Orbit were put out of action.

Karolinska University Hospital in Solna and Huddinge, St Erik’s Eye Hospital, Södertälje Hospital, healthcare centres, geriatric and psychiatric hospitals and departments, municipal and private care throughout Stockholm County Council (SLL) use the patient record system TakeCare. TakeCare is also used at Visby Hospital, at healthcare centres and in municipal care in the municipality of Gotland. It was not possible to use the patient record system for 2.5 – 3 hours.

The backup systems, which the departments were instructed to use to cope with interruptions to the central patient record system TakeCare, were only exceptionally used. In addition, battery capacity in the local computers used for this purpose was insufficient, as TakeCare was out of action for a long time.

Great difficulties arose in establishing contact with the control centre at the hospital during the power failure, since the control centre was quickly flooded with incoming automatic alarms and phone calls. Those responsible did not utilise the hospital’s disaster plan to deal with the situation. The deputy hospital director, two of the hospital’s medical directors and the head of the emergency room monitored developments instead. They took a decision early on that all incoming ambulances should be diverted to the hospital in Solna and that a mobile standby generator should be collected from Solna. They informed other hospitals; the official on call (TiB) in Stockholm County Council was later contacted by the SOS-Alarm emergency call centre.

The duty technician in the control centre called in service staff with the necessary electrical skills who could locate the fault and restore the power supply in the hospital.

The hospital’s generator set failed to start, which was entirely correct since the fault occurred in the hospital's electrical installation. There was voltage from outside in the public mains supply throughout. A smaller part of the hospital was therefore not affected, including the main building with emergency rooms, radiology and the control centre. If reserve power had been generated and connected in this situation, a conflict between reserve power and ordinary power from outside might have caused even greater problems.

Service engineers disconnected the high-voltage cable with the earth fault and replaced it with a new one within a few days following the incident. The cable was put into service on 23 April.

Principal author

Lars-Göran Angantyr, the National Board of Health and Welfare

Co-authors

Eskil Häggström, Rejlers Ingenjörer AB, consultant to the Swedish Emergency Management Agency (KBM)

Per Kulling, Health Threats Unit, Directorate General of Health and Consumers (DG SANCO), European Commission, Luxembourg (formerly employed at the National Board of Health and Welfare)

External reviewer

Helge Brändström Senior Consultant, Department of Anaesthesiology and Intensive Care the Norrland University Hospital in Umeå, emergency chief physician, Västerbotten County Council.

Persons interviewed and reporters

Svante Baehrendtz, Medical Director, Karolinska University Hospital

Anders G. Eriksson, former Acting Head of Communications Section, IT Operation & Infrastructure, Karolinska University Hospital

Bengt Eriksson, former Director of Department, Department of Anaesthesiology and Intensive Care, Karolinska University Hospital, Huddinge

Per Gillström, Deputy Hospital Director, Karolinska University Hospital

Margareta Hamark, Director of Information, Karolinska University Hospital

Sigga Kalman, acting Director of Department, Department of Anaesthesiology and Intensive Care, Karolinska University Hospital, Huddinge

Lennart Malmström, Consultant Physician, disaster and emergency services, Karolinska University Hospital, Solna

Kai Mäkinen, Head of Electromedicine Section, Department of Biomedical Engineering, Karolinska University Hospital, Solna and Huddinge

Mikael Olsson, Service Manager Locum AB

Erna Pettersson, Medical Director, responsible for quality, Karolinska University Hospital

Jorge Rodrigues-Inácio, Head of Biomedical Engineering and Director of Department, Department of Biomedical Engineering, Karolinska University Hospital

Krister Samfors, Site Manager, Dalkia Management, at Karolinska University Hospital, Huddinge

Albert Virta, acting Head of Service Section, IT Operation & Infrastructure, Karolinska University Hospital

Heikki Teriö, Head of Research, Development and Education, Department of Biomedical Engineering, Karolinska University Hospital

Gunnar Öhlén, Director of Department, Department of Emergency, Karolinska University Hospital, Huddinge

Editor

Susannah Sigurdsson, the National Board of Health and Welfare

Read the full Summary

Year: 2009
Article number: 2009-126-91
Format: POD
Pages: 81
Language: Engelska
Price (VAT included): 76 kr

Contact

Susannah Sigurdsson
+46 (0)75-247 30 00