OXYTOTE

Description of Event or Problem

PATIENT TRANSPORTED TO RADIATION ONCOLOGY WITH NO OXYGEN RUNNING. PATIENT HAD TANK AND NASAL CANNULA. PATIENT WAITING IN HALL FOR TREATMENT AND NOT CONNECTED TO WALL O2. PATIENT BROUGHT INTO TREATMENT ROOM WHERE IT WAS FOUND THAT THE PTS O2 TANK WAS NOT ON. THE TANK WAS SET TO 2L, BUT THE SIDE VALVE WAS IN THE CLOSED POSITION. THE OXYTOTE DEVICES REQUIRE A TWO-STEP PROCESS TO TURN ON THE OXYGEN DELIVERY. 1. TURN ON THE OXYTOTE, AND 2. TURN ON THE OXYGEN TANK. THIS DESIGN POSES A RISK TO OUR PATIENTS. DESPITE EDUCATION, THIS RESULTS IN HALF OF THE OXYGEN FAILURES HAVE BEEN DUE TO USER ERROR.