Description of Event or Problem · 0
PT DNR DNI, ON ARDS NET PROTOCOL INTUBATED, SEDATED. PLAN FOR THE PAST FEW DAYS HAS BEEN TO WEAN PT SEDATION, WAKE UP AND ATTEMPT BREATHING TRIAL TO SEE IF PT CAN TOLERATE WEANING OFF VENTILATOR. PT INCREASINGLY AGITATED THIS AFTERNOON, HR 110S, SBP(SYSTOLIC BLOOD PRESSURE) 200S, VENT DYSSCHRONY INCREASED, TEMP INCREASED TO >39 C, CUFF LEAK INCREASED WITH AGITATION AND CPOT >3, WOB INCREASING, FIO2 INCREASED TO 100%. IN ATTEMPT TO MAKE PT MORE COMFORTABLE SO HE CAN BREATH EASIER, SEDATION STARTED/RESTARTED PER MD ORDERS WITH DEXMEDETOMIDINE AND PROPOFOL ORDERED WITH GTT TITRATIONS TO BE FOLLOWED BY RN. MEDICATION TITRATED PER PROTOCOL BASED ON CPOT SCORES, YET DESPITE INCREASE IN TITRATIONS OVER TIME (AS ORDERED), PT NOT IMPROVING, CPOT STILL >3, VENT STILL NOT SYNCHRONOUS, WOB STILL HIGH, SBP STILL 200S ,HR 100S. AFTER 30 MINUTES OF TITRATING, RN NOTED 4 WAY STOPCOCK USED TO INFUSE DEXMEDETOMIDINE AND PROPOFOL GTT WAS CRACKED AND NOT INFUSING INTO PATIENT LINE, RATHER ALL THE MEDICATION HAD BEEN INFUSING INTO PILLOW DUE TO CRACK IN EQUIPMENT. PT IN NOTABLE DISTRESS X30 MINS TO 1 HR R/T THIS FAULTY STOPCOCK. ONCE NOTED, REMOVED FAULTY EQUIPMENT AND ATTACHED MEDICATION DIRECTLY TO PT R IJ TLC WITH NO ISSUE, OMITTING 4 WAY BRAUN STOPCOCK. PT RESPONSIVE TO MEDICATION, DOSES REDUCED PER MD VERBAL ORDERS AFTER BEING BRIEFED ON SITUATION WITH FAULTY EQUIPMENT. EQUIPMENT SAVED BY UNIT CNL (CLINICAL NURSE LEADER). PT DISTRESS SUBSIDED ONCE MEDICATION PROPERLY INFUSING ONCE FAULTY EQUIPMENT REMOVED.