Description of Event or Problem · 1
A 79-YR-OLD FEMALE PT WAS TRANSPORTED TO ENDOSCOPY AT 0726 3/7/94, FOR A BRONCHOSCOPY. DURING THE PROCEDURE THE PHYSICIAN INTUBATED THE PT USING THE BRONCHOSCOPE AND A #8 ENDOTRACHEAL TUBE. THE BRONCHOSCOPE WAS REMOVED AND A SWIVEL OXYGEN ADAPTER WAS CONNECTED AND TAPED. THE WHITE MEMBRANE OF THE ADAPTER REMAINED IN PLACE. THE BRONCHOSCOPE WAS THEN REINSERTED. OXYGEN SATURATION DECREASED TO 84%, AND THE PHYSICIAN GAVE ORDERS TO INCREASE THE OXYGEN FLOW RATE TO 15 1/MIN. APPROX 30-60 SECONDS LATER, FACIAL EDEMA, ABDOMINAL DISTENSION, AND NECK DISTENSION WERE NOTED. THE PHYSICIAN EXTUBATED THE PT, POSITIONED HER ON THE RIGHT SIDE AND MAINTAINED THE AIRWAY. A CODE WAS CALLED. THE PT WAS REINTUBATED AND CARDIOPULMONARY RESUSCITATION WAS IN PROGRESS. A CHEST X-RAY WAS TAKEN WHICH INDICATED BILATERAL PNEUMOTHORAX. A RIGHT AND LEFT CHEST TUBE WAS INSERTED AND CARDIOPULMONARY RESUSCITATION CONTINUED. HOWEVER, THE PT DID NOT RESPOND TO AGGRESSIVE MEDICAL TREATMENT AND EXPIRED AT 0836.DEVICE LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: SATISFACTORY CONDITION. THERE WAS NOT MULTIPLE PATIENT INVOLVEMENT.INVALID DATA - ON DEVICE SERVICE/MAINTENANCE. NO DATA - REGARDING DATE LAST SERVICED. SERVICE PROVIDED BY: INVALID DATA. INVALID DATA - SERVICE RECORDS AVAILABILITY.NO IMMINENT HAZARD TO PUBLIC HEALTH CLAIMED. DEVICE USED AS LABELED/INTENDED.DEVICE WAS EVALUATED AFTER THE EVENT. METHOD OF EVALUATION: VISUAL EXAMINATION. RESULTS OF EVALUATION: OTHER. CONCLUSION: INVALID DATA. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: MAYBE. CORRECTIVE ACTIONS: INVALID DATA. THE DEVICE WAS NOT DESTROYED/DISPOSED OF.