Description of Event or Problem · 1
A HOSPICE PT'S FAMILY MEMBER CALLED IN TO SAY THEIR LIQUID O2 BASE WAS MISTING A LOT AND WAS THIS OKAY. CSR SPOKE WITH A TECH WHO DECIDED BASED ON THE INFO RECEIVED THAT WHILE IT WAS NOT AN EMERGENCY, A TECH WOULD GO OUT AND CHECK. SINCE PT WAS ON 15 LITERS CONTINUOUS O2, 2 BASES WERE USED AT 7 1/2 LITERS EACH. AT SUCH A HIGH LITER FLOW, MISTING IS COMMON. A DRIVER WENT OUT AND THE FLOW METERS WERE TURNED UP ALL THE WAY CAUSING THE BASES TO FREEZE OVER. THE FAMILY MEMBER STATED THE NURSE HAD DONE THIS; CHANGING THE SETTINGS ORIGINALLY SET BY THE TECHNICIANS. THE DRIVER THAWED OUT THE ONE FROZEN BASE, ADJUSTED THE FLOW METERS BACK TO THE ORIGINAL SETTINGS AND INSTRUCTED THE FAMILY MEMBER ON WHAT TO WATCH FOR AND DO. ABOUT 1 1/2 HRS LATER AN EMERGENCY CALL CAME IN THAT THE EQUIPMENT HAD MALFUNCTIONED, WAS SPEWING O2 EVERYWHERE AND THE PT WAS IN RESPIRATORY DISTRESS. BY THE TIME THE DRIVER GOT THERE, IN AROUND 8 MINS, THE PT WAS ON THE WAY TO THE HOSP BY AMBULANCE. THE DRIVER PICKED UP BOTH THE LIQUID BASES AND BROUGHT THEM TO THE WAREHOUSE WHERE THEY WERE PICKED UP BY AN INDEPENDENT CO TO BE EVALUATED. THE PT WAS REVIVED, BUT DID DIE THE FOLLOWING DAY.