FLOWMETER, TUBE, THORPE, BACK-PRESSURE COMPENSATED

Description of Event or Problem

PATIENT HAD PRESENTED TO THE EMERGENCY DEPARTMENT. PATIENT WAS PLACED ON 6 L/MIN O2 [OXYGEN] VIA NASAL CANNULA. DURING THE VISIT, PATIENT WAS TAKEN TO IMAGING AND THEN RETURNED TO THE EMERGENCY DEPARTMENT. PATIENT HAD ALSO BEEN OUT OF BED TO USE THE BATHROOM. THE BEDSIDE MONITOR ALARMED FOR LOW SPO2. AN ED TECH RESPONDED TO THE ALARM AND FOUND THE PATIENT WITH A SPO2 OF 66%. THE PATIENT WAS SITTING UP IN BED, AWAKE, ALERT, AND ORIENTED. PATIENT WAS EATING FOOD AT THE TIME AND HAD SHE BECOME MORE SHORT OF BREATH. ED TECH FOUND THAT THE PATIENT TO BE ON 6 L/MIN MEDICAL AIR VIA NASAL CANNULA, INSTEAD OF O2. THE TUBING OF THE NASAL CANNULA WAS CONNECTED TO THE MEDICAL AIR FLOW METER, AND NOT THE OXYGEN FLOW METER. PATIENT WAS PLACED BACK ON O2 AND SPO2 GRADUALLY INCREASED.