Prevention of Medical Errors 2011

Mary Mckay DNP, ARNP

Scope of the Problem

IOM study- To Err is Human-1999 44,000 - 98,000 Americans die in hospitals each year from medical errors Medication related errors result in 7,000 deaths each year. $37.6 billion and 50 billion dollars in associated costs

Second Victim Phenomenon

Source: Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36:233-240.

Is Health Care Safer Today?

Difficult to Assess: Lack of universal reporting system Under reporting Lack of consensus regarding terminology/definitions of what constitutes an error

Why are errors under reported?

1. Historically a punitive approach has been taken leading to fear :
Loss of reputation Loss of job Disciplinary action by professional board Malpractice

Why are errors under reported?

2. Difficult to use reporting systems 3. Time constraints

4. Sweep it under the rug mentality

Is Health Care Safer Today?

Agency for Healthcare Research and Quality- National Healthcare Quality Report 2008

National Initiatives
Patient Safety and Quality Improvement Act of 2005
Legislation that establishes a confidential reporting structure in which hospitals, health care professional and entities can voluntarily report information on errors to Patient Safety Organizations to facilitate development of patient safety strategies.

Simulation and Safety

What are the benefits of learning through simulation? Allows for learners to perform in an environment that is as close as possible to a real patient scenario Learners acquire and practice skills in a safe environment Mistakes made while training will not harm a real patient An opportunity to improve patient safety thru teamwork and critical event training.( American Society of Anesthesiologists, 2008).

Institute for Healthcare Improvement

Adverse Drug Events (ADE) Catheter-Associated Urinary Tract Infections (CAUTI) Central Line Associated Blood Stream Infections (CLABSI) Injuries from Falls and Immobility Obstetrical Adverse Events Pressure Ulcers Surgical Site Infections Venous Thromboembolism (VTE) Ventilator-Associated Pneumonia (VAP) Other Hospital-Acquired Conditions

Posted on: April 12, 2011

http://www.ihi.org/IHI/Programs/ImprovementMap/
Institute for Health Care Improvement @ IHI.org

WHO- Initiatives
Clean Care is Safer Care Safe Surgery Saves Lives
WHO Safety Check list

Common Terminology
Medical Error Adverse Event Near Miss Sentinel Event

What is a Medical Error ?

According to the Institute of Medicine(1999) a medical error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

What is an ADVERSE EVENT ?

An event in which a negative outcome occurred as a result of medical intervention rather than from the underlying medical condition.

What is a Near Miss ?

An event or situation that could have resulted in an accident, injury or illness ,but did not, either by chance or through timely intervention. Warning sign Increased reporting needed

Case Study #1
A 55 year old man presented to an ER with fever. Following an assessment the MD ordered an IV antibiotic and an antifungal IV drug- Diflucan . The nurse requested the Diflucan from the pharmacy. A 50ml bottle of Diprivan (sedative hypnotic agent) was sent to the ER erroneously labeled as Diflucan 100mg/ml. The nurse noted the bottle contained an opaque solution rather than the usual clear plastic bag of Diflucan she was familiar with. While she was initiating a phone call to the pharmacy for clarification, a MD demanded her immediate assistance.
Reference: http://www.ahrq.gov

Case Study
She returned to the patient and hung the Diprivan via the patients central line. The IV pump alarmed air in line almost immediately. While removing the air from the line the nurse was once again alerted to the discrepancy she had noted earlier. She removed the Diprivan and contacted the pharmacy. Fortunately, the patient had not received any of the Diprivan yet.
Reference: http://www.ahrq.gov

What Happened ?

What is a Sentinel Event?

The Joint Commission developed a Sentinel Event Policy and database in 1996 of all reported events. Used to analyze events to provide information to healthcare organizations to deter future occurrences.

Joint Commission

What is a Sentinel Event?

A sentinel event is defined as an unexpected occurrence involving death or serious physical, or psychological injury, or risk thereof Sends a signal or warning that requires immediate attention

Agency for Healthcare Research and Quality

Sentinel Events Alert

In order to communicate information related to sentinel events to healthcare organizations in a timely manner the Joint commission utilizes Sentinel Events Alert. Identifies specific sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future.

What is a Root Cause and Analysis ?

A process for identifying the causative factors involved in the occurrence of a sentinel event A root cause is the most basic reason for the failure or inefficiency of a process Focuses primarily on systems/processes not individuals

JC Identified Root Causes of Sentinel Events for All Categories

Communication Orientation/Training Patient Assessment Availability of information Staffing levels Physical environment Issues

JC Identified Root Causes of Sentinel Events for All Categories

Continuum of care Competency/ Credentialing Procedural compliance Alarm systems Organizational Culture

FAILURE MODES & EFFECT ANALYSIS

Another method to prevent errors Process applied prior to actual error Examines a system/process for possible high risk points of error Possibly redesign the process to eliminate chance of failure Pilot test Implement the process Reevaluate

Why Do Errors in Health Care Occur ?

Medical errors most often result from a complex interplay of multiple factors. Only rarely are they due to the carelessness or misconduct of single individuals
L. Leape, MD.

WHY DO SYSTEMS FAIL?

COMPLEXITY VARIABILITY INCONSISTENCY TIME CONSTRAINT HUMAN INTERVENTION HIEARCHICAL CULTURE TIGHT COUPLING

Types of System Errors/Failures

Active errors/failures involve personnel and parts of the health care system that are in direct contact with the patient. Their actions may result in errors that have a direct impact on patient safety Referred to as errors occurring at the sharp end. Reason, JT. (1990). Human Error. New York, NY:Cambridge University

Types of System Errors/Failures

Latent errors/failures involve individuals such as managers, administrators and policy makers Their actions or decisions may lead to a negative impact on patient safety. Tend to be less obvious. Referred to as errors occurring at the blunt end
Reason, JT. (1990). Human Error. New York, NY:Cambridge University

Types of System Errors/Failures

Blunt End Latent

Sharp End Active

2011 JC National Patient Safety Goals

Goal 1: Improve the accuracy of patient identification A. Use at least two patient
identifiers(neither to be the patients room number) when providing care, treatment or services

 A 47 y/o male who was PCP. While undergoing treatment he had several skin lesions biopsied. Several days later an MD(PCP) noted the results in the EMR were positive for cancer. This prompted the PCP to recommend Hospice care. Later that day the hospital MD noted this was an error. The biopsy results were from another patient. The medical team met with the patient to explain the error.

What Happened?
This example involves both active and latent errors

Reference: http://www.ahrq.gov

JC Patient Safety 2011

Eliminate Transfusion Errors

2011 National Patient Safety Goals

Goal 2- Improve the effectiveness of communication among caregivers

2011 National Patient Safety Goals

2A. For verbal or telephone orders or for telephonic reporting of critical test results,verify read -back of the complete order or test result by the person receiving the order or test result

2011 National Patient Safety Goals

2B. Standardize a list of abbreviations, acronyms and symbols that are NOT to be used throughout the organization.

Case Study
An 81 year old female with a history of chronic Atrial Fib who was receiving warfarin developed asymptomatic runs of ventricular Tachycardia http://www.ahrq.gov

Case Study
Unit RN contacted MD who was involved in a sterile procedure and gave a verbal order to the procedure nurse Someone in the verbal order said 40 of K. The unit RN Wrote the order as Give 40mg Vit K IV Now

Case Study
Clarification of order The hospital pharmacist contacted Was obtained 40 mEq of KCL PO The MD concerning The high dose and the route
Simultaneously the unit RN had obtained the Vit K on over ride From the Pyxis system and given the IV dose

Case Study
Clarification of order The hospital pharmacist contacted Was obtained 40 mEq of KCL PO The MD concerning The high dose and the route
Simultaneously the unit RN had obtained the Vit K on over ride From the Pyxis system and given the IV dose

Case Study
The RN attempted to contact the MD but Was told he was busy. The MD was not Notified until the next day. Heparin was Initiated and warfarin retitrated. No Long term consequences were suffered.

Do Not Use Abbreviations

Abbreviation U for unit Mistaken for Suggestion Zero, four, cc Unit International unit Daily or every other day

IU IV or 10 International unit Q.D. Each other Q.O.D.

Abbreviation
Trailing zero (1.0mg)

Mistaken for Suggestion

Decimal point is missed Read as 10 mg Never write a zero after a decimal point and always use a zero before a decimal point

Lack of a leading ero (.1mg) MS MSO4 MgSO4

Read as 1 mg Confusion Morphine sulfate vs Magnesium sulfate Write out name of drug

Abbreviation mcg TIW

Mistaken for Suggestion Milligram Write out microgram Three times a week Write out meaning bedtime half strength

HS

Multiple meaning

2011 JC National Patient Safety Goals

2C. Measure, assess and, if appropriate take action to improve the timeliness of reporting and timeliness of receipt by the responsible licensed caregiver of critical test result and values.

A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital for continued wound care and intravenous (IV) antibiotics for (MRSA) osteomyelitis of the heel. She was on IV vancomycin and began to have frequent, large stools. The attending physician ordered a test for Clostridium difficile on Friday, and was then off for the weekend. That night, the test result came back positive. The lab called infection control, who in turn notified the float nurse caring for the patient. The nurse did not notify the physician on call or the regular nursing staff. Isolation signs were posted on the patient's door and chart, and the result was noted in the patient's nursing record.

On Monday, the physician who originally ordered the C. difficile test returned to assess the patient and found the isolation signs on her door. He asked why he was never notified and why the patient was not being treated. The nurse on duty at that time told him that the patient was on IV vancomycin. The float nurse, who had received the original notification from infection control, stated that she had assumed the physician would check the results of the test he had ordered. Due to the lack of follow-up, the patient went three days without treatment for C. difficile, and continued to have more than 10 loose stools daily. Given her advanced age, this degree of gastrointestinal loss undoubtedly played a role in her decline in functional status and extended hospital stay.

AHRQ

How Important is Communication and Patient Safety?

70-80% of health care errors are caused by human factors associated with interpersonal interactions (Schaefer,1994)

CASE STUDY
An 83 y/o male with a history of COPD, GERD, and atrial fib was admitted to a large teaching hospital for placement of a pacemaker via the left subclavian vein. Following the procedure the patient had an CXR which showed no pneumothorax. He was sent to recovery for overnight monitoring.
Reference: http://www.ahrq.gov

Case Study
The patient had shortness of breath and complained of left sided back pain. The nurse informed the on call intern who examined the patient (for the first time) and ordered a chest x-ray. When the nurse called the intern at 8 pm to check for results, the Intern stated he was signing out the x-ray to the night float resident. In the meantime the patient was feeling a little better with oxygen.

Case Study
At 10 pm the nurse called the float resident who had been too busy with an emergency to check the x-ray results. At midnight the nurse gave report to the next shift noting that the resident had not called with any bad news. The next morning the radiologist called to inform the nurse the patient had a large left pneumothorax. A chest tube was inserted nearly 23 hours following the x-ray. Fortunately the patient did not suffer any long term harm.

What Happened?
After further follow up it was discovered that the night float resident had mistakenly examined the CXR that had been taken immediately following the surgery instead of the later one. This case illustrates how a handoff can jeopardize patient safety. A standardized method for communicating transfer of care can decrease the risk.

Behaviors That Impede Patient Safety

Reluctance or refusal to answer questions- avoidance Rude or condescending comments Threatening body language Verbal abuse I am in charge. Just do it Threats to reputation

Behaviors That Support A Culture of Safety

Collaboration Respect Interdisciplinary rounds/conferences Open, honest and direct communication Supportive non-punitive reporting Goal directed interactions

Agency for Healthcare Research and Quality

2011 National Patient Safety Goals

Goal 3 Improve the safety of using medications

Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs

Case Study
A 36 y/o woman with chronic renal failure & diabetes was transferred from a nursing home to the hospital for treatment of an infection. Bicitra (citric acid)30ml four times a day was ordered on admission. The pharmacist filled the order with Polycitra instead ( contains citric acid & Potassium citrate). The patient drank the entire dose.

Case Study
The nurse on the next shift noted the empty container. The MD was notified and a STAT potassium level was > 8mEq/L. (Normal is 3.5-5) and her blood glucose was 600mg/dl. The patient was treated with Kayexalate and insulin without complications.
Reference: http://www.ahrq.gov

What Happened?

2011 National Patient Safety Goals

- Label all medications, medication containers(syringes, medicine cups,etc) or other solutions on & off the sterile field

Case Study
A woman was injected with chlorhexidine (topical anti microbial) instead of the intended contrast media during a cerebral angiogram procedure. The clear pink tinged chlorhexidine solution was placed in a basin identical to that used to hold clear colored contrast media. Neither basin was labeled so both solutions looked very similar.
ISMP Medication Safety Alert! August 2005 Vol3 Issue 8

Case Study
The patient experienced an acute severe chemical injury to the blood vessels in her leg. Within two weeks her leg was amputated. She then suffered a stroke and organ failure leading to her death.
ISMP Medication Safety Alert! August 2005 Vol3 Issue 8

What Happened ?
Is this an example of an active or latent failure?

What Happened ?
It is an example of both. The lack of labeling on the basins is an active failure. The change in cleaning solutions is a latent failure.
Blunt End Sharp End

Additional Medication Safety Issues

The National Coordinating Council for Medication Error Reporting & Prevention defines a medication error as follows: A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. Such events may be related to professional practice, health care products, procedures and systems, including prescribing; order communication; product labeling, packing, and nomenclature; compounding; dispensing; distribution, administration; education;monitoring;and use.

How Often Do Medication Errors Really Occur ?

According to the IOM study more than 7000 deaths occur each year related to medication errors. Another study found that as many as 1 in every 5 medications reach the patient in error.

Medication Errors
Keep in mind that the reporting of medication errors is thought to be grossly under reported !
Reporting agencies include the FDA, US Pharmacopeia via Medmarx , ISMP and JCAHO

Where in the Process do Medication Errors Occur?

Reference: http://www.ahrq.gov

Where in the Process do Medication Errors Occur?

Most errors occur during the prescribing /ordering process. About 50% of those prescribing errors are caught prior to reaching the patient. Greater than one third of errors occur during administration but only 2% of these errors are caught prior to reaching the patient.
ISMP Medication Safety Alert, November 2005

Patient is the Last Line of Defense

Errors made during the administration process are much more likely to reach the patient and are associated with those errors that cause harm. Encourage patient and families to ask questions.
ISMP Medication Safety Alert, November 2005

TYPES OF ERRORS
Unauthorized drug Improper dose Omission Prescribing Wrong time Wrong Patient Extra dose Wrong administration technique Wrong method of preparation Wrong dosage form Wrong route Failure to monitor

Do All Medication Errors Result in Harm to Patient?

According to MEDMARX 2002 Data report (USP) out of 192,477 reported med errors-82 % were classified as non-harmful. However, a reported 3,193 were classified as harmful and 20 as fatal errors.

Could you safely transcribe this order ?

Reference: http://www.ahrq.gov

Could you safely transcribe this order ?

Reference: http://www.ahrq.gov

Key Points
Written orders must be clear and legible ! Clarify any order that is questionable including sound alike/ look alike drugs.

Patients age, sex,current medications, diagnosis, co morbidities, concurrent conditions, laboratory values, allergies and past sensitivities must be available to prescriber

Case Study
A patient was admitted to a teaching hospital with suspected vasculitis. During rounds the senior resident instructed the intern to give the patient one gram of steroids. Following rounds the interns ordered Prednisone 20mg tabs 50 pills PO x 1 now. The pharmacist contacted the intern to clarify the order. She suggested to the intern that the order should probably be given in an IV form. The intern refused to change the Order despite the pharmacists suggestion to contact the senior resident for clarification. The intern added to give Maalox with the steroids. The patient reluctantly took the fifty 20 mg pills and developed mild nausea and heartburn. The following day the senior resident found the error and changed the order to the IV form.
Reference: http://www.ahrq.gov

What Happened?
The intern did not seek clarification as suggested by the pharmacist, who is an expert in pharmacology. Lack of interdisciplinary approach to patient care. The intern may have been fearful of the senior residences reaction to seeking clarification. The pharmacist did not follow the chain of command by calling the senior resident when the discrepancy was not addressed by the intern. QUESTION INCONSISTENCIES-YOUR PATIENTS SAFETY IS IN YOUR HANDS

Medication Errors : Prevention Strategies

Adhere to standards of medication administration -8 Rights Communicate with the patient /family Identify medications with high risk for error and institute specific protocols

Medication Errors : Prevention Strategies

Training & competency assessment Decrease distractions Computerized order entry Automated dispensing devices

Medication Errors : Prevention Strategies

Proper storage & labeling Bar coding-decreases errors in administration Increased clinical Pharmacists

2011 Patient Safety Goals

Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

Case Study
Three neonates died at a hospital as a result of accidental heparin overdoses. A pharmacy technician inadvertently filled the automated dispensing cabinet with 1ml vials of heparin containing 10,000 units/ml instead of the1ml vials of heparin10 units/ml. The nurses did not notice the discrepancy and the heparin was administered to the neonates.
ISMP Medication Safety Alert Oct 2006 4/10

Recommendations
In order to prevent this tragedy from happening again the following recommendations have been made: 1. Eliminate 10, 000 units/ml concentration vials stocked in the hospital. If this concentration remains in the pharmacy, keep the vials separate from other concentrations. Require an independent double check of drug. Reduce look alike/ sound alike drug packaging The vials of heparin had similarities that may have contributed to the error.

2. 3.

For all recommendations see reference

Unintended Medication Discrepancies at the Time of Hospital Admission

More than half of patient have 1 unintended medication discrepancy at hospital admission

6% Severe harm potential

61% No harm potential 33% Moderate harm potential

Reference: http://www.ahrq.gov

Unintended Medication Discrepancies at the Time of Hospital Admission

Cornish,Knowles & Marchensano(2005)found greater than 50% of patients had at least 1 medication discrepancy upon hospital admission. The most common error was omission of a regularly used medication. Obtaining an accurate medication history at the time of admission is critical to prevent such errors.
Reference: http://www.ahrq.gov

2011 National Patient Safety Goals

Goal 8- Accurately and completely Reconcile Medications across the continuum of care

2011 Patient Safety Goals

Comparing Current and Newly Ordered Medications (NPSG.08.01.01) B. Communicating Medications to the Next Provider (NPSG.08.02.01) C. Providing a Reconciled Medication List to the Patient (NPSG.08.03.01) D. Settings in which Medications Are Minimally Used (NPSG.08.04.01)

2011 National Patient Safety Goals

Goal 7- Reduce the risk of health care associated infections
A. Meeting Hand Hygiene Guidelines B. Preventing Multidrug-Resistant Organism Infections C. Preventing Central LineAssociated Blood Stream Infections D. Preventing Surgical Site Infections

TEST YOUR KNOWLEDGE

Which is the most frequently occurring nosocomial infection?
A. Urinary tract infection B. Pneumonia C. Vascular Catheter related

Which of these are risk factors for development of nosocomial infections?

A. B. C. D. E. Age Urinary catheter >24hrs Mechanical ventilation Severe underlying disease Extended stay in acute or chronic care facility

Additional considerations include: Overuse of antimicrobials Contaminated equipment-instruments Poor HANDWASHING

Additional Safety Concerns

Reduce the Potential of Patient Harm resulting from falls

Falls in the Elderly

Falls are a leading cause of death in people 65 and older. Approximately 50% of those that fall suffer injuries that reduce mobility and independence. One third of those that sustain hip fractures require nursing home placement Ten percent of fatal falls for older adults occur in hospitals.

Fall Risk Factors

>65 years of age Inability to understand or follow directions Confusion Altered level of consciousness/ delirium Inability to use call light Impaired vision or mobility Unsteady gait Dizziness/fainting Recent history of falls

Fall Risk Factors

Medication Therapy Hx of nocturnal/urgency/ frequency in elimination Hx of seizures Surgical Procedure Orthostatic hypotension or hypertension Children in cribs Use of assistive devices

Meds Requiring Fall Alert

Tricyclic Antidepressants Antipsychotics Sedative-Hypnotics Antihypertensives Antihistamine/Anticholinergics Hypoglycemic agents Diuretics/Laxatives Anticonvulsants Muscle Relaxants Narcotic Analgesics

Fall Assessment-High Risk

Identify high risk patients and communicate to staff-Morse Fall Scale Place yellow fall identification band on patients wrist Observe patients identified at risk for falls every 2 hours Review patients medications that may increase the risk of falls on a daily basis.

Interventions- Initiate Safety Measures

Dangle feet from bed prior to sitting/ambulation Assist with ambulation Apply fall alert ID armband Place bed/chair in low position Ensure correct use of least restraint Free environment of clutter Review medications Consider interdisciplinary consult Document assessment, interventions, response Educate patient & significant others

Reporting Falls: SBARD

A method of communication used to report a critical situation to a physician including falls S = Situation B = Background A = Assessment R = Recommendation D = Document

Additional Safety Concerns

Prevent health careassociated pressure ulcers

2011 Patient Safety Goals

The organization identifies safety risks inherent in its patient population.

High Risk Patient Populations

Elderly Pediatric Language Barriers Vision Impairment

Case Study
An elderly blind patient was hospitalized for treatment of a deep vein thrombosis(clot). His discharge medications included injections of a anti coagulate. A nurse and pharmacist provided the patient with written information sheets and counseling regarding self administration of his medications. Neither noticed that the patient was blind.
Reference: http://www.ahrq.gov

Case Study
Several days following discharge the patient called the office and told the nurse he had a bag full of medications including injections, but he had not taken any of them since he could not read the instructions. The patient had to be readmitted to the hospital for continuation of anticoagulate therapy.

What Happened?
False assumptions regarding the patients visual acuity Inadequate discharge teaching. Written information is insufficient. They did not have the patient return demonstrate the injection procedure. Over 1 million persons living in the US are legally blind. Proper assessment is essential to patient education.

Interventions For High Risk Patients

Medication training/competency Interpreter use Available patient education materials Large print Available outside resources

Case Study
Following an overdose a 26 year old woman was admitted for observation with a 72 hour hold by psychiatry. A 24 - hour attendant was placed with the patient. The patient was to go to x-ray but requested to go to the bathroom first. She was left in the bathroom alone. The attendant and transporter began to talk.
Reference: http://www.ahrq.gov

Case Study
Upon return to patients room, the nurse became concerned and found patient with her gown tied around her neck, standing on the upside down garbage can. She was seconds from stepping off and hanging herself. Fortunately no harm came to the patient.

NEVER LEAVE PATIENT UNATTENDED

Psychiatric Patients
According to other resources the number is under reported. Approximately 1500 suicides have occurred in hospitals.
Review of 76 cases found only 40% of inpatients who committed suicide were admitted for suicidal ideation. Prevention Strategies

2011 Patient Safety Goal

Conduct a pre procedure verification Process A. Conducting a Pre-Procedure Verification Process B. Marking the Procedure Site C. Performing a Time-Out

Patient Safety Considerations

Encourage patients active involvement in their own care as a patient safety strategy.

Improve recognition and response to change in a patients condition.

Rapid Response Teams

Team Composition Goals- Early intervention Process Outcomes

Patient/Family
Patients and family members can provide additional safety checks. Encourage patients and families to ask questions. Inform patients of their rights. Educate patients and family members on all aspects of their care. Provide written material as well as verbal.

Available Resources for Patient Education include

Institute for Safe Medication Practices access www.ismp.org Agency for Healthcare Research & Quality access www.ahrq.govhttp://www.ihi.org/IHI/ Institute for Healthcare Improvement access: http://www.ihi.org/IHI/

TEAM WORK IS THE KEY

Moving pains
A 90-year-old woman was admitted to the acute care ward of the school's teaching hospital with a urinary tract infection and pneumonia. After developing hypoxemia, on hospital day 2, she was placed on 2 L/min oxygen by nasal cannula. On hospital day 3, her hypoxemia worsened, as did her mental status. A head CT was ordered. She was placed on a nonrebreather mask (NRM) at 15 L/min to maintain her oxygen saturations. This change in respiratory status occurred while the primary nurse was occupied by the critical needs of another patient, so another nurse and the respiratory therapist placed the patient on the NRM.

 The primary nurse completed the transport stability scale (TSSa local instrument used to assess a patient's stability for transport and to determine the need for a nurse or physician to travel with the patient) at the nurses' station in preparing her patient for transport to the CT scanner. Because the nurse was unaware of the change in her patient's respiratory status, she recorded that the patient required only 2 L/min oxygen by nasal cannula. Accordingly, the TSS score did not signal a need for a nurse or physician to accompany the patient. Therefore, the patient was taken to the CT scanner by two transport personnel/escorts.

In the elevator, one of the transporters realized that she no longer heard the flow of oxygen and that the NRM bag was deflated. When they returned to the floor, she immediately called for help. The patient was reconnected to the wall oxygen source in her room at 15 L/min. However, by that time, the patient was noted to be severely hypoxemic and markedly short of breath. Over the next hour, her condition continued to worsen. Because she did not wish to be intubated, she expired approximately 30 minutes after arrival to the floor. A root cause analysis later attributed the death, at least in part, to inadequate delivery of supplemental oxygen and insufficient observation during the transport process.

As the transporters prepared to leave the floor with the patient, one of them noticed that the patient had labored breathing. He suspected that a nurse should travel with them but did not question the nurse's assessment on the transport stability form. During transport, the patient continued breathing through her NRM, which was connected to an oxygen tank. Once the patient arrived in radiology, the CT technician noticed that NRM bag was deflated and the oxygen tank had a regulator that limited oxygen delivery to 4 L/min. The technician connected the NRM to the wall oxygen source at 15 L/min for the study and located an appropriate tank (that would allow higher-flow oxygen) for the trip back to the unit. After the study, the patient was switched to this new tank at 15 L/min and awaited transport. The two transporters arrived, and the patient left radiology to return to her room.