REGULATOR, PRESSURE, GAS CYLINDER

Description of Event or Problem

PATIENT WITH STABLE VITAL SIGNS WAS TAKEN OFF CIRCUIT AND BAGGED IN THE USUAL MANNER TO BE TRANSPORTED OFF UNIT TO CT FOR IMAGING STUDY. A FULL OXYGEN TANK WAS TAKEN FROM THE SUPPLY ROOM TO BE USED FOR TRANSPORT AND THE FLOWMETER READ FULL PRIOR TO USE. WHEN PATIENT WAS BEING TRANSPORTED, HIS OXYGENATION DROPPED INTO THE 70S, HIS BLOOD PRESSURE DROPPED INTO THE 30S/10S, AND HIS HEART RATE DROPPED INTO THE 40S. PATIENT LOST HIS PULSES AND WAS CODED WITH ONE ROUND OF CARDIOPULMONARY RESUSCITATION, AND ONE DOSE OF EPINEPHRINE. RETURN OF SPONTANEOUS CIRCULATION WAS EVENTUALLY ACHIEVED, THE PATIENT WAS MONITORED, AND LAB RESULTS SENT FOR ANALYSIS. AN HOUR LATER, IT WAS DISCOVERED THAT THE AIRGAS OXYGEN TANK THAT WAS USED FOR TRANSPORT WAS NOT WORKING CORRECTLY. THE AIRGAS E-CYLINDER OXYGEN REGULATOR WAS NOT PROPERLY WORKING AS IT INDICATED IT WAS A FULL TANK CONTAINING 1700 PSI OF OXYGEN, WHEN IN REALITY IT WAS NOT.