Robert Michael: Hospital nursing policies changes regarding portable oxygen containers

Inner Circle member Robert Michael, Rockville, Maryland, represented the family of a female resident of a rehabilitation hospital who required oxygen.  While being transferred to physical rehabilitation, the nurse switched her to a portable oxygen tank without checking its oxygen gauge.  After her rehabilitation session, the woman was returned to her room and left in her wheelchair while the nurse went to find an assistant to help put her back into her bed.  While the nurse was away the woman's oxygen ran out and she died sitting in her wheelchair.  As a part of the resolution of the case, the hospital instituted a nursing policy change requiring the reading and recording of portable oxygen containers on any patient being transported within the hospital.  The hospital also agreed to set up a nursing program in the name of the deceased woman where each year a CME course for the floor nurses would be conducted covering patient safety issues, including the need to check portable oxygen tank level gauges.