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Single or Multiple Incident: Single
Date: 3/1/2017 12:00:00 AM
Country: Canada
Organization: Manitoba Health

This alert describes a fatal patient incident related to a failure to provide oxygen because of an empty oxygen tank. A patient diagnosed with aspiration pneumonia was treated with bi-level positive airway pressure (BiPAP) in the emergency department. When being transferred to the inpatient medical unit, the BiPAP was changed to oxygen via a non-breathe mask. When the client arrived on the medical unit, they were noted to be having difficulty breathing and soon after developed agonal respirations. The oxygen tank used for the transfer was examined and found to be empty. The patient had a respiratory arrest and resuscitation was unsuccessful. Contributing factors are described and recommendations to prevent similar incidents provided

Additional Details

oxygen tank, non-breathe mask, oxygen regulator

Failure to Provide High Flow Oxygen during Intra-facility Transfer