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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

Device:
oxygen tank, non-breathe mask, oxygen regulator
Medication/Gas/Fluid:
oxygen

Communication
  1. Post information cards at oxygen storage tank locations.
Rules / Policies / Procedures
  1. Implement policies that clearly identify the requirements for safe patient transport and include the identification of personnel and the mandatory competencies with respect to both patient assessment and equipment management.
  2. Define role expectations for health care aides who participate in patient transfers and require oxygen therapy.
  3. Utilize quick reference laminated cards with the START mneumonic that outlines safety checks for delivering oxygen therapy prior to transporting a patient. The reverse of the card contains an accurate estimate table of the time remaining in oxygen tank based on oxygen flow rates.
  4. Develop a standardized method for information transfer between Emergency Department and unit staff to ensure the necessary communication occurs for safe patient transfer.
  5. Review and revise clinical transfer sheets to include documentation of the client’s oxygen requirements and notification of the Respiratory Department regarding client transfer.
Training
  1. Include policy and guidelines related to administration of oxygen therapy to patients in the clinical orientation for new staff.

Failure to Provide High Flow Oxygen during Intra-facility Transfer