INCIDENT REPORT:

PATIENT NAME: UNKNOWN UNKNOWN UNKNOWN

MRN: 02487127

AUG 10, 2021:

0300: Patient unknown unknown-02487127, with Tracheostomy on 2LPM via SN was desaturating at
0300 hr. We called RT to reconnect but as per them they need Dr.’s order and referred to Dr. Rajab and
with order to reconnect to ventilator and give sedation. After the reconnection, patient maintained
saturation of 93-94%.

0345: Patient saturation is ranging from 85-90%, and informed RT to do something with ventilator and
patient and referred top Dr. Rajab. The RT did not do anything, as per the RT 90% saturation is
acceptable. RT informed that patient case is Neuro and not good to keep patient desaturating and Dr.
Rajab ordered to keep saturation more than 90%. But still RT did not do anything, as per him the patient
just need sedation and even they will increase the FiO2 to 100% will not improve the Saturation. During
that time, patient is not fighting against the ventilator and No spontaneous breathing and 3 RT in front
of the patient talking. But RT still didn’t do anything and told to take ABG and still no one did it.

0350: Dr. Rajab did assessment and ordered to do Ambu Lavage, suctioning and X-ray. Bedside staff Ms.
Femina and Me (Charge Nurse) did with Dr. Rajab, while RT is just in front looking what we are doing.
ABG done at 0500 hr.

0530: The RT assigned came to me and explain his side. And told the reason why he wasn’t do the ABG
right after that and didn’t do any adjustment in Ventilator. Informed him, that he should explained to us
and do something coz 85% is not good to patient, instead of just talking to other RT’s in front of patient.
Being the Charge Nurse, it is my duty to look for all the patient and to ensure that they’re safe and
received and adequate care. I told him I’m not expert in ventilator since this is their expertise that’s why
I asked his service.