Description of Event or Problem · 0
RESPONDED TO PEDIATRIC RAPID RESPONSE, PATIENT WITH INCREASED RR (RESPIRATORY RATE) AND WOB (WORK OF BREATHING). WAS WEARING AEROSOL FACE MASK WITH CONTINUOUS ALBUTEROL RUNNING AT 10MG/HR. UPON CLOSER INSPECTION, NOTICED NO STEAM COMING FROM AEROSOL MASK. AFTER LOOKING BACK TO THE AEROGEN MEDICATION CUP, NOTICED THE CUP WAS NOT ONLY FULL, BUT OVERFLOWING ONTO THE FLOOR. AEROGEN WAS CURRENTLY NOT RUNNING. IT WAS TURNED ON TO CONTINUOUS MODE AND RUNNING EFFECTIVELY UPON INITIALLY LEAVING ROOM. IT WAS UNKNOWN HOW LONG IT HAD NOT BEEN RUNNING FOR. NEBULIZER WAS RESTARTED, HOWEVER, PATIENT EVENTUALLY NEEDED UPGRADED TO ICU FOR INCREASED WOB DUE TO NOT RECEIVING STEROID. PER UNIT REPORT, "IN THIS EVENT, THE PATIENT EXPERIENCED WORSENING SYMPTOMS AS A RESULT OF THE NEBULIZER BEING FOUND OFF WHEN STAFF CHECKED BACK ON THE PATIENT. IN REVIEW OF THE EVENT, IT WAS IDENTIFIED THAT WE CAN¿T DETERMINE IF THE NEBULIZER MALFUNCTIONED OR IF IT WAS PROGRAMMED INCORRECTLY. THE NEB ITSELF HAS A FEATURE WHERE YOU CAN PROGRAM FOR 30 MINUTES OR FOR CONTINUOUS, BUT IT IS EASY TO MIS-PROGRAM. ADDITIONALLY, THERE IS NO ALARM TO ALERT YOU THAT THE MACHINE IS GOING TO TURN OFF SIMILAR TO HOW AN IV PUMP ALARMS TO ALERT STAFF THE TREATMENT IS FINISHED.".