LESSONS FROM
PAT I E N T S A F E T Y
EVENTS
JUNE 2013
Issue: PATIENT FALLS INVOLVING OXYGEN TUBING
INCIDENT #1
REDUCING THE RISK OF HARM
This resident was walking towards his doorway. He was
using oxygen and the tubing connection was long so that
he could walk freely. He had an unwitnessed fall and when
staff arrived noted the tubing was twisted around his legs.
The resident had an x-ray which revealed an oblique periprosthetic fracture at the level of the base of the greater
trochanter. Analgesics and weight bearing as tolerated was
recommended for treatment. There was no serious harm
identified.
All of the Review Committees (CIRC) recognized the inherent
conflict between encouraging mobility and independence
by providing tubing extensions, and increasing the risk for
falling. Additionally, they mentioned the other risk factors
(dementia, medication use, unfamiliar surroundings etc)
that are included in the constellation of factors predisposing
patients to falls.
INCIDENT #2
The patient stated that he was ambulating to the BR with his
wheeled walker and O2 when the O2 extension tubing got
caught around his wheeled walker and he tripped and fell.
INCIDENT #3
The patient required continuous O2 and the extended
oxygen tubing was utilized. The patient stated that the
extended oxygen tubing wrapped around the walker and
caused the fall.
However, The CIRC identified that this particular risk was
not included in the current regional Clinical Practice
Guideline for Falls Prevention and Management, and made a
recommendation that it be included when the CPG is revised.
ADDITIONALLY, SOME LOCAL SOLUTIONS
THAT HAVE BEEN IMPLEMENTED ARE:
•
•
•
Coiling the tubing up near the head of the bed to
prevent this from occurring.
Shortening the tubing when the resident begins to
ambulate again
Trialing the use of O2 holders on walkers
www.calibex.com/walker-oxygen-holder/
zzcalibex2zB1z0--search-html
INCIDENT #4
The patient had an un-witnessed fall in her room. She
apparently got out of bed and was going to the bathroom
and fell when her Oxygen (O2) tubing became caught on the
bedside table. The results of the X-ray indicated a fractured
left femoral head, and a compression fracture in the thoracic
spine. The patient underwent a left hip hemiarthroplasty
monopolar procedure
INCIDENT #5
When this patient was in her room she would ambulate
independently and would use the wall oxygen. To enable the
patient to go to the bathroom and move about in the room
an extension was applied to the oxygen tubing. The patient
got the tubing caught in the wheels of the walker and fell.
She sustained a left hip fracture
OTHER RISK-REDUCING IDEAS
THAT WE DISCOVERED ARE:
•
•
•
Placing coloured tape markers every 12” along the
tubing, or using coloured tubing to make it easier to see.
Using a “tubing spool” or other product; for example
www.youtube.com/watch?v=V3etQFIDtbw&feature=
player_detailpage
Providing verbal and written instructions to patients and
families to decrease the risk of a fall; for example:
www.aurorahealthcare.org/FYWB_pdfs/X26161.pdf
REDUCE THIS RISK
Are you aware of any other mitigating actions that can be
taken to reduce this risk? If so, please contact the WRHA
Patient Safety Unit at 204 926-8058 or email
[email protected]
WRHA Quality and Patient Safety Unit
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