[160524]
At approx 12:30pm on july 12, 1999, a vascular shunt was placed in a pt for the purposes of dialysis. The procedure was successful and the pt was prepared to return to the nursing unit. The oxygen connection was removed from the wall oxygen source and attached to a portable cylinder. The oxygen cannula was then attached to the pt's existing tracheostomy. The pt was then transported by bed to the intensive care unit. The transport was completed within a few minutes. On arrival to the intesive care unit, the pt was noted to be in ventricular fibrillation. The pt then became apneic and sustained a cardiac arrest. Cardio-pulmonary resuscitation was implemented including medications (calcium and sodium bicarbonate) and intravenous fluids. The pt failed to respond and was pronounced dead after approx ten mins. At this time, it was discovered that the portable cylinder used to transport the pt was a carbon dioxide cylinder. The physician involved in the case concluded that the c02 had probably contributed to the pt's cardiopulmonary arrest. On examination, it was noted that the original tank used for transport was aluminum o2 tank with green paint near the top and the co2 tank was a steel container that was similar in color to the o2 tank that was originally used for transport to the operating room. The gunmetal gray color of the co2 tank was significantly distored by rust. In addition, the co2 tank contained a standardized (dept of transportation) green label that reads "non-flammable". This standard green label was located near the top of the tank where the green paint was located on the original aluminum oxygen cylinder. In addition, the co2 tank was equipped with a flowmeter and a green nipple adapter that was similar in appearance to the flowmeter normally used for oxygen. The regulators on the two canisters looked identical with the exception of the words "carbon dioxide" written in small print on the flowmeter portion. In essence, the pin indexing system that was designed to constrain this type of event was over-ridden by a look-alike product. Further review revealed that the color and type of oxygen tanks located in the facility were inconsistent. Tanks can be steel painted in light or dark green. They may also be aluminum (gray) in color with a green painted band at the top. The co2 tanks had a greenish haue with rust marks and scratches on them. Both have dept of transportation labels which have a green background. The vendor was notified.
Patient Sequence No: 1, Text Type: D, B5