Description of Event or Problem · 1
A CLEAR PLASTIC O2 CONNECTOR -CHRISTMAS TREE- WAS FOUND TO BE SEALED AT THE END -MANUFACTURE DEFECT-. THIS BLOCKED THE OXYGEN FROM FLOWING THROUGH THE CONNECTOR. ALTHOUGH THE O2 -E-TANK- WAS TURNED ON, AND THE O2 GAUGE INDICATED 2 LPM FLOW THE CLEAR CONNECTOR'S OBSTRUCTED DISTAL END PREVENTED THE O2 FROM REACHING THE PATIENT. NORMALLY THE CENTER OF THE CONNECTOR IS HOLLOW ALLOWING THE O2 TO FLOW FROM THE TANK THROUGH THE O2 TUBING, TO THE PATIENT. THE PATIENT WAS BEING TRANSPORTED VIA WHEELCHAIR. HIS OXYGEN SATURATION BEGAN DROPPING SLOWLY, LIPS TURNED BLUISH AND HE WAS DIFFICULT TO AROUSE. O2 SAT WAS 76%. A NON-REBREATHER MASK WAS TRIED, WITHOUT EFFECT. THE DEFECTIVE CONNECTOR WAS IDENTIFIED AS THE PROBLEM, REPLACED WITH A PATIENT CONNECTOR AND THE PATIENT RETURNED TO O2 SATS IN THE 90'S. LOOKING AT THE CONNECTOR, IT APPEARS TO BE NORMAL. HOWEVER, THE END THAT THE O2 TUBING WOULD ATTACH TO -THE NIPPLE END- IS NOT HOLLOW. THE END IS SOLID, FILLED WITH CLEAR PLASTIC. THIS CLEAR PLASTIC APPEARS TO BE THE SAME MATERIAL AS THE REST OF THE CONNECTOR. NO EXTRA MATERIAL PROTRUDES FROM THIS END. IT IS FLAT, THUS MAKING THIS DEFECT EVEN MORE DIFFICULT TO NOTICE.