+A perfect storm of errors in ER.
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My Mom almost died in a perfect storm of errors in ER. This is a letter that I later wrote to her pulmonologist.
I'd like your help in reporting an incident involving my Mother that occurred in ER on {date). As you know, she died the following day of respiratory failure brought on by Post Polio.
The ER doctor had ordered Dilaudid 2 mg IV push before the CT scan of her lungs, to decrease the pain of lying on her back. I had told the doctor that - as a Post Polio - Mom wouldn't do well with that high of a dose, but he didn't listen to me.
Beginning right after she received the Dilaudid, she was asleep and barely arousable, although her respiratory effort looked like her usual while asleep. She dropped gradually from 95% to 78% on 100% oxygen using a non-rebreather mask. That was before the CT scan, and the nurse knew it.
I didn't yet realize that Mom was dying, although I was on her side when she said she didn't want CPR or a vent.
There were several problems while she was in ER; I won't go into them here. The problem I want to address involved the non-rebreather mask. A nurse took her to have the CT scan of her lungs. She was hooked up to an E-tank for transport. However, when she returned to ER, the oxygen was not reconnected to the wall. As you know, an E-tank will not last very long while set at 10 to 15 liters/minute. My guess is that it would last maybe 10 to 15 minutes?
I didn't catch it at first. All at once, I noticed her SpO2 starting to drop. 76%, 73, 71. I turned her call light on. 68. 66. I ran out into the hall, but didn't see anyone close by. 58. 55. I finally saw that the reservoir to the non-rebreather mask was becoming flaccid. Frantically, I followed the tubing to the empty tank, and reconnected it to the wall.
Her SpO2 stayed at 50%.
I ran out into the hall again, found two people talking, and told them that my Mom's SpO2 was only 50! They came right in. By that time, she read 61%, 65%, and gradually back to 78%.
Mom could have died right then. Someone else could die from a similar error. I don't want to raise a stink here, but this is a problem that needs to be addressed. Please consider this as an incident report.
There are several things that went wrong. The ER was short-staffed. The alarms on the pulse oximeter had been disabled. Perhaps this was because there was no way to set the low O2 alarm below 78%?
The transport person was right to refuse to transport Mom; her status was too unstable. But perhaps the nurse who did accompany her was not used to the routine of making sure the oxygen was reconnected to the wall.
Is it a normal routine to make sure the oxygen is reconnected to the wall? It should be.