Two Dead in Oxygen, Nitrogen Mix up

Article

Nursing home officials in Bellbrook, Ohio accidentally hooked a nitrogen tank to an oxygen-delivery system, causing the deaths of the two patients.

An assistant fire chief said a nitrogen tank was included in a delivery to Carriage by the Lake Nursing Home.

The center should only receive oxygen tanks. Robert Gill, spokesperson for the nursing home said the center hasn't used nitrogen as a matter of practice.

Allegedly there was also an oxygen label covering a nitrogen label on the tank. The word "nitrogen" was covered.

The Dayton suburb center called firefighters to report a patient's heart had stopped. As the firefighters were working on the first patient, a nurse came in to report another person in cardiac arrest. Then another person came into the room to report two more patients were in trouble. The firefighter then realized there was a contamination in the building.

Pauline Tays, 70 died at the nursing home. Helen Tomlin, 76, was pronounced dead at the hospital. Eight other residents were taken to hospitals and four were treated and released. The other four remain hospitalized.

The affected residents had all been on a shared oxygen system in the same wing of the 84-bed nursing home. When officials realized a contamination at fault, the system was immediately shut down. Patients were put on individual oxygen tanks thereafter.

Information from www.usatoday.com

Newsletter

Stay prepared and protected with Infection Control Today's newsletter, delivering essential updates, best practices, and expert insights for infection preventionists.

Recent Videos
 Brenna Doran PhD, MA, hospital epidemiology and infection prevention for the University of California, San Francisco, and a coach and consultant of infection prevention; Jessica Swain, MBA, MLT, director of infection prevention and control for Dartmouth Health in Lebanon, New Hampshire; and Shanina Knighton, associate professor at Case Western Reserve University School of Nursing and senior nurse scientist at MetroHealth System in Cleveland, Ohio
In a recent discussion with Infection Control Today® (ICT®), study authors Brenna Doran PhD, MA, hospital epidemiology and infection prevention for the University of California, San Francisco, and a coach and consultant of infection prevention; Jessica Swain, MBA, MLT, director of infection prevention and control for Dartmouth Health in Lebanon, New Hampshire; and Shanina Knighton, associate professor at Case Western Reserve University School of Nursing and senior nurse scientist at MetroHealth System in Cleveland, Ohio, shared their insights on how the project evolved and what the findings mean for the future.
 Futuristic UV Sanitizer with Sleek Design on a white background.  (Adobe Stock 1375983522 by Napa)