Apr 05:

It was the middle of the night. The CRNA and I brought a patient to the ICU immediately after exploratory laparotomy. The patient was extubated, and saturating 100% on face mask oxygen we provided in transit. While the CRNA began giving report to the R.N., I helped the nurse by hooking up the oxygen, monitors, etc. Within a few seconds, the patient's oxygen saturation had fallen from 100% to 94%. Not dangerous...but unusual. The patient seemed to be breathing O.K...but there was more fogging of the mask than I was used to seeing. Of note, the ICU was nearly pitch black dark, which is how they kept it at night for two reasons: 1) easier for patients to sleep 2) easier for ICU staff to sleep. I peered through the gloom toward the oxygen flowmeter. I then asked the nurse: "How many liters per minute (of oxygen) is the patient getting?"

She squinted. "Ten".

"No," I replied, "One".

I hurried to the wall and showed her that the neonatal flowmeter attached to my very adult patient was physically capable of delivering only 1 (one) liter/minute of oxygen MAX, rather than the 10 l/m the patient needed.

We quickly grabbed another flowmeter from over an empty ICU bed, and the patient's oxygen immediately increased to 100%.

I confiscated the flowmeter and wrote up a formal hospital Incident Report; I delivered both personally, by hand, to the office of LtCol C., RN, the hospital Risk Management/QA officer in charge (OIC). She told me she would investigate, then put the word out around the hospital-- an APB for inappropriate neonatal flowmeters in adult areas...

Days went by...didn't hear anything through e-mail, etc.; I started to wonder...Hmmmm....

Subsequently, I discussed the oxygen flowmeter issue (1 l/m max) with LtCol C., twice on way out of hospital near ER, when I happened to run into her:

Apr 05:

First time she told me she had investigated and found that the flowmeter I had discovered was very old-- plastic yellowed and discolored-- called manufacturer-- didn't even make them anymore; she assumed that MGMC had gotten it from some base that had closed down. Also, she found two oxygen flowmeters on the surgical ward (2H) jury-rigged/duct taped to medical air cylinders. She said she was going to present this to the General when she got more information...

21 May 05:

Second time, she told me that the hospital was going to put out a warning notice Air Force...even DoD-wide..."after the (JCAHO) inspection"-- obviously, the command didn't want JCAHO to know about this near-miss sentinel event, which was being swept under the rug of "Quality Assurance" rather than frankly admitted to, so that MGMC could pass the impending JCAHO audit without any annoying questions about near-fatal equipment problems...

The scary thing to me is that the bad flowmeter was located at the head of the bed directly to the left of the ICU entrance-- which is where, in my 5 years at MGMC, all ward codes were brought for stabilization/evaluation after initial resuscitation. Who knows how long it had been there before I noticed? Who knows if someone (or more than one) had died needlessly because they hadn't gotten nearly enough oxygen during their code? Imagine if a very fragile patient had to try to make due with one liter of oxygen per minute...let's see, average of 12 breaths per minute would mean 83 ml of oxygen per breath...while the body would be putting out CO2, which would rapidly lead to CO2 buildup in the context of a tight-fitting mask or NRB...not very good for the home team, that scenario...

Remind me again about the Integrity First stuff? Isn't it "Cover-up First So We Can Pass JCAHO Without Any Egg On Our Face"? And the "Excellence in All We Do"...fuggedaboutit!