Nurse's mistake puts man in coma in Kyoto Japan - page 2

by nursebedlam 3,390 Views | 13 Comments

Nurse's mistake puts man in coma in Kyoto Japan 20 May 2004 A nurse at Kyoto Municipal Hospital in Nakagyo Ward, Kyoto, Japan, caused a male patient in his 50s to go into a coma when she accidentally blocked his oxygen... Read More


  1. 0
    The O2 sat monitoring should have helped the nurse. Everytime there is a change in O2 delivery, we check how would the patient tolerate it. So, the CP arrest could have been prevented when she saw the O2 sat dropping. Maybe there are no resp therapist in Japan that could have helped the busy nurse.
  2. 0
    Quote from ethelbsnrn
    The O2 sat monitoring should have helped the nurse. Everytime there is a change in O2 delivery, we check how would the patient tolerate it. So, the CP arrest could have been prevented when she saw the O2 sat dropping. Maybe there are no resp therapist in Japan that could have helped the busy nurse.
    Excellant point!

    Unfortunately, I also agree that the nurse was in error in deciding to change the O2 route. If the dr only says to change the AMOUNT of O2 being delivered, but doesn't write that it should be changed to a different site, then it should stay at the site where it already was. Even if she didn't know any better about the trach being used for breathing, she still shouldn't have made that decision to change it to nasal herself.

    I'm sure she didn't intend to harm the patient and we all make mistakes. I just hope I never make one this serious. It's scary what an unintentional error can cause.
  3. 0
    notice how the article just had to put "the 50 yr old nurse" as if her age was a factor! Honestly!
  4. 0
    Quote from DOCS RN
    The doctor wrote a poor order. It should have read. "Reduce oxygen flow from 4L/min to 2L/min via trach tube."
    Bad nursing judgement, plain and simple...The doc holds NO responsibility...

    Should docs write "40 mg Lasix slow IV push" or "Lanoxin .125 mg IV over 1-2 minutes"

    NO.


    It's the nurse's responsibility to know this, PERIOD.


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