Description of Event or Problem · 1
THE PT WAS ABLE TO BREATHE ON HIS OWN FOR APPROX 30 MINUTES AT A TIME. AFTER A FAMILY MEMBER CHANGED BREATHING CIRCUIT ON THE VENTILATOR, PT CLAIMED THAT HE WAS NOT GETTING ENOUGH BREATH FROM THE VENTILATOR. THE FAMILY MEMBER DECIDED TO SWITCH PT TO THE OTHER VENTILATOR. AGAIN PT CLAIMED THAT HE WAS NOT GETTING ENOUGH BREATH. AT THAT POINT, FAMILY DISCONNECTED PT FROM THE SECOND VENTILATOR AND STARTED USING A RESUSCITATION BAG TO VENTILATE HIM. THE PT THEN SEEMED FINE FOR AWHILE. HOWEVER, AFTER A FEW MINUTES, THEY NOTICED A LOT OF BLOOD FROM HIS TRACHEOSTOMY. PARAMEDICS WERE CALLED AND THE PT WAS TAKEN TO THE HOSPITAL. HE WAS STABILIZED, BUT DIED EARLY THE NEXT MORNING. IT IS STILL UNKNOWN WHETHER THE VENTILATOR WAS MALFUNCTIONING AND RESULTED IN THE ADVERSE EVENT. (PLEASE ALSO REFER TO MDR REPORT # 2023050-2006-00028 FOR THE SECOND VENTILATOR.)