Patient Death From Loss of Oxygen Supply

By ThinkReliability Staff

The California Department of Public Health recently announced that a California hospital will be fined $50,000 for a situation that led to the death of a patient.  On March 5, 2009, a patient died of cardiac arrest after his portable oxygen tank ran out.  The patient was not breathing adequately on his own, because he had pneumonia in both lungs.  A patient death is always an impact to the patient safety goals.  The fine is an impact to the organization and compliance goals.  Additionally, a patient’s oxygen tank running out of oxygen (regardless of whether it caused a death) is an impact to the patient services goal.  These impacts to the goals give us a starting point for our investigation.

The patient death was caused by cardiac arrest, caused by insufficient oxygen.  The patient had insufficient oxygen and insufficient supervision.  Had the patient been properly supervised (as required), a medical staffer should have noticed the issue before it came to this point.  The patient was unable to breath on his own because of the pneumonia and so was placed on oxygen.  The patient was placed on portable oxygen in order to be transported to the radiology department for an ultrasound.  Although there was the capability within the radiology department for the patient to be hooked up to the wall oxygen supply, there was no policy to do so, and the patient remained on the portable oxygen supply.

According to hospital procedures, when a patient is being transported, the responsibility for the safety of that patient lies with the transporter.  A hospital policy allows for patients to be transported by untrained personnel in the case that a patient is stable, and this is indicated on the Transport Communication Form.  This patient was transported by an untrained person; however, no Transport Communication Form was completed or signed.  Whether or not the patient was considered ‘stable’ is unknown.  For reasons that are unclear, the transport person left the patient in the radiology department and did not return.  Eventually, the Ultrasound Technician returned the patient to his room.   It was then realized that the patient was not breathing and the patient was connected to the wall supply.  However, it was too late and the patient was unable to be revived.  Although the Ultrasound Technician was trying to aid the patient, she did not verify that the patient was breathing, either because it was not her responsibility or she was unaware of the patient’s oxygen requirements.  The transport person was both not around, and not trained for this type of work.  Although the hospital policy required an RN or a Respiratory Therapist to regulate the oxygen flow rate, none were around.

Shortly after this incident, the hospital implemented new and clarified policies regarding patients on oxygen, and how they were to be transported.  These solutions, along with the rest of the information from the investigation, can be seen by clicking “Download PDF” above.

Information used for this investigation was found in the report by the California Department of Public Health.