BEUDAMED
    FDA Adverse Event Death Summary report: N

    FLOWMETER 15LPM US OXY OHMEDA PT SWIVEL

    MDR report key: 11243084 · Received January 28, 2021

    Report

    Report Number
    11243084
    Event Type
    Death
    Date Received
    January 28, 2021
    Date of Event
    January 17, 2021
    Report Date
    January 25, 2021
    Product Code
    CAX
    Adverse Event
    Yes
    Report Source
    User Facility report
    Reporter Location
    CA
    Reporter Occupation
    NURSE

    Narratives

    Description of Event or Problem · 0

    DURING TRANSPORT, THE PATIENT'S OXYGEN SATURATION WAS 90% AND HIGHER, HEART RATE (HR) 68 WHILE BEING HAND VENTILATED ON 100% FIO2. UPON ARRIVAL TO NEW BED, THE TRANSPORT VENTILATOR (HAMILTON)'S OXYGEN SOURCE (E-TANK) WAS CONNECTED TO THE WALL OXYGEN OUTLET. THIS WAS DONE VIA FLOWMETER USING THE 50 PSI VALVE. ALARM BEGAN SIGNALING "OXYGEN FAILURE." THE OXYGEN WAS IMMEDIATELY DISCONNECTED AND RECONNECTED TO AN ADJACENT BED'S WALL OXYGEN OUTLET VIA FLOWMETER. APPROXIMATELY 1-2 MINUTES LATER, ALARM SIGNALED "OXYGEN FAILURE." THE OXYGEN WAS THEN IMMEDIATELY DISCONNECTED AND RECONNECTED TO THE E-TANK. THE ALARM NO LONGER SIGNALED "OXYGEN FAILURE." THE PATIENT'S OXYGEN SATURATION DROPPED TO 30-49%, THE PATIENT WAS REMOVED FROM VENTILATOR AND BAGGING BEGAN WITH 100% FIO2. THE PATIENT'S HEART RATE DROPPED IN THE 40'S BPM. CODE BLUE WAS INITIATED, BEFORE PATIENT¿S DEATH.

    Description of Event or Problem · 1

    DURING TRANSPORT, THE PATIENT'S OXYGEN SATURATION WAS 90% AND HIGHER, HEART RATE (HR) 68 WHILE BEING HAND VENTILATED ON 100% FIO2. UPON ARRIVAL TO NEW BED, THE TRANSPORT VENTILATOR (HAMILTON)'S OXYGEN SOURCE (E-TANK) WAS CONNECTED TO THE WALL OXYGEN OUTLET. THIS WAS DONE VIA FLOWMETER USING THE 50 PSI VALVE. ALARM BEGAN SIGNALING "OXYGEN FAILURE." THE OXYGEN WAS IMMEDIATELY DISCONNECTED AND RECONNECTED TO AN ADJACENT BED'S WALL OXYGEN OUTLET VIA FLOWMETER. APPROXIMATELY 1-2 MINUTES LATER, ALARM SIGNALED "OXYGEN FAILURE." THE OXYGEN WAS THEN IMMEDIATELY DISCONNECTED AND RECONNECTED TO THE E-TANK. THE ALARM NO LONGER SIGNALED "OXYGEN FAILURE." THE PATIENT'S OXYGEN SATURATION DROPPED TO 30-49%, THE PATIENT WAS REMOVED FROM VENTILATOR AND BAGGING BEGAN WITH 100% FIO2. THE PATIENT'S HEART RATE DROPPED IN THE 40'S BPM. CODE BLUE WAS INITIATED AND TIME OF DEATH WAS 1421.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    140100 FLOWMETER 15LPM US OXY OHMEDA PT SWIVEL MEDICAL GAS FLOWMETER, THORPE TUBE CAX FM-15UO-OHPT-S

    Patients

    Seq Age Sex Outcome Treatment
    1 23725 DA Death