BEUDAMED
    FDA Adverse Event Injury Summary report: N

    WESTERN/SCOTT FETZER

    MDR report key: 17404907 · Received July 27, 2023

    Report

    Report Number
    17404907
    Event Type
    Injury
    Date Received
    July 27, 2023
    Date of Event
    June 26, 2023
    Report Date
    June 27, 2023
    Manufacturer
    WESTERN/SCOTT FETZER COMPANY
    Product Code
    CAN
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    User Facility report
    Reporter Location
    ID
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Description of Event or Problem · 0

    RRT WAS TAKING THE PATIENT ON A WALK WITH RN AND THE PATIENT'S FATHER. AS THEY WERE PASSING THE NURSING STATION ON PEDS THAT PATIENT WAS MOTIONING/ASKING FOR SUCTIONING. WE PULLED TO THE SIDE TO SUCTION THE PATIENT AND NOTED THAT HE WAS STARTING TO TURN BLUE AND DESATURATING. I INCREASED THE FLOW ON THE OXYGEN TANK AS THIS PATIENT WAS ON AN HME. THE PATIENT CONTINUED TO DESATURATE AND STARTED TO LOSE CONSCIOUSNESS AND THAT'S WHEN THE NURSE AND I DECIDED TO QUICKLY MOVE THE PATIENT INTO THE TREATMENT ROOM ON PEDS. WHEN I UNPLUGGED HIM FROM THE OXYGEN TANK I NOTICED THAT THERE WAS NO FLOW FROM THE TANK COMING OUT. I QUICKLY HOOKED UP THE BAG TO THE FLOWMETER IN THE TREATMENT ROOM AND STARTED TO BAG THE PATIENT. HIS COLOR, CONSCIOUSNESS, AND SATURATION QUICKLY CAME BACK. RN RETRIEVED ANOTHER OXYGEN TANK AND THE PATIENT WAS SAFELY TRANSPORTED BACK INTO HIS ROOM. VITAL SIGNS STABLE. DURING THE EVENT IT WAS NOTED THAT THE TANK WAS NOT ALARMING APPROPRIATELY. *OXYTOTE READING TANK AS FULL OR PSI AVAILABLE, BUT NO PRESSURE OR FLOW. *OXYTOTE NOT ALARMING TO LOW PSI.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1258165 WESTERN/SCOTT FETZER REGULATOR, PRESSURE, GAS CYLINDER CAN WESTERN/SCOTT FETZER COMPANY MNDR-600

    Patients

    Seq Age Sex Outcome Treatment
    1 1460 DA Male Life Threatening| R