INTELLI-OX PORTABLE OXYGEN TANK

Description of Event or Problem

PATIENT REMAINED CONNECTED TO INTELLI-OX (BRAND NAME) PORTABLE OXYGEN TANK WHICH DEPLETED TO EMPTY AND DID NOT ALERT THE TEAM MEMBER. TEAM MEMBERS HAVE PROVIDED FEEDBACK DURING MULTIPLE CAUSE ANALYSIS REVIEWS THAT THERE WAS NO AUDIBLE ALERT AS DESIGNED WHEN ONE QUARTER OXYGEN VOLUME REMAINS OR 15 MINUTES AT THE CURRENT DELIVERY RATE REMAINS. ADDITIONALLY, SHARING CONCERNS THAT ONCE THE TANK IS EMPTY THERE IS NO FURTHER ALERT/SOUND FROM THE TANK. THIS IS AN ON-GOING ISSUE WITH ALL OF THE INTELLI-OX TANKS.