Nurse's mistake puts man in coma in Kyoto Japan

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    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 flow, The Yomiuri Shimbun learned Tuesday.

    The hospital has admitted responsibility for the accident. The Kyoto prefectural police have been investigating the incident on suspicion of professional negligence.

    According to the hospital, the patient underwent surgery for lung cancer in mid- April. He began receiving oxygen through a tracheostomy tube Friday.

    On Sunday, as his condition improved, a doctor ordered the 50-year-old nurse to halve the oxygen supply from four liters per minute to two liters per minute.

    However, the nurse mistakenly stopped using the tracheostomy tube and delivered oxygen to the patient through a tube in his nose. As a result, the patient went into cardiac and respiratory arrest and has been in a coma ever since.

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  2. 13 Comments...

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    The doctor wrote a poor order. It should have read. "Reduce oxygen flow from 4L/min to 2L/min via trach tube."
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    Not a bad order. If the patient has a trach and that is being used, you do not change the patient to a nasal cannula without an order for it. The trach was there for a reason........................
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    While I think the nurse should have clarified the order with the MD before changing the pt. from a TC to NC, I do agree the MD should have written "....via trach tube" as part of his order.
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    Have you ever cared for a patient with a trach? Unless that trach stoma has a button over it, the patient will only be breathing thru the trach and not his
    nose. So where he needed the oxygen was to his stoma, not to his nose.
    If the order just said to decrease the flow, that is all that you do, you do not change how it is being delivered.
  7. 0
    I do think it was poor judgment on the nurse's behalf to switch the route of the oxygen, but I don't think it would've killed the doctors to write the order completely with the amount of oxygen and route they want.

    It really doesn't specify how exactly the order was written though.

    I think all orders should be written exactly as they want them performed and leaving no room for interpretation. That would probably help to decrease errors.
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    They may do things differently over there. Here we use percentages, docs at this facility don't write orders 2L on trached patients. It's in perecentages. So bad order from the doc.

    Trying not to be too judgemental, but the nurse was horribly incompetent in my opinion. Giving NC on a trached patient???? She'd be racked over the coals here, spit out to the nursing board and be defending her license. (Which is not to say that isn't happening over there.) I feel for her, we all make mistakes.
  9. 0
    Some trachs are fully cuffed (which eliminates 'normal' breathing and speech for the patient normally) some are fenestrated and uncuffed, where the patients are in the process of weaning to eventually have it closed...and breathe and speak normally again. This nurse lacked knowledge of her patient, the equipment and anatomy and sounds like the doctor contributed....I have never heard of ordering lpm via a trach...%'s are used and 'via trach collar' (or in context of 'per volume vent' orders) to clarify administration.

    If this nurse was not experienced enough to know for sure whether the patient was capable of breathing through nose/mouth, then she failed to ask appropriate questions to ensure safety for her patient, and WAS negligent under the law, IMO.

    Very sad for this patient and his family and my heart goes out to them. I am also sad when nurses are prosecuted for unintentional mistakes, but it seems the wave of the future.
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    Quote from mattsmom81
    I am also sad when nurses are prosecuted for unintentional mistakes, but it seems the wave of the future.

    While I sounded very judgemental, I realize that at any moment I could be in that nurses shoes. A momentary lapse in judgement, a rushed moment, or pure ignorance of a situation and I can make a fatal unintentional mistake. It could be any one of us.

    People should be supported in their errors. The "process" looked at to find how and why the mistake was made. But raking someone over the coals isn't going to help matters.

    I agree though it's the wave of the future. We live in a society that wants to place blame on a person. Find someone to blame, make them pay lots of money, and get rid of them like yesterday's trash.
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    I'm afraid I have to agree with mattsmom. And for the people blaming this one on the physician...I don't agree. I'm, of course, speaking from the perspective of a critical care nurse so please keep that in mind. In our unit we are "expected" to have such knowledge that a trachestomy is used for breathing. Therefore, the oxygen source must be applied to the trachestomy for adequate ventilation and perfusion. I don't understand how this could happen, I'm sorry.

    Before you start flaming me for opinion, please keep in mind that I also believe we need more information in this case to judge this particular nurse. I'm just basing my opinion on our medical care system and what is expected of us registered nurses. If this happened in our unit (i.e. critical care), the nurse would lose her license...and rightfully so. This, IMO, is poor patient care, lack of critical thinking skills, and downright negligence.

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