A system problem: where was the failure?

A-72-year-old man with a previous diagnosis of Chronic Obstructive Pulmonary Disease had a diagnosis of pneumonia after three days with high fever, cough and a productive sputum. He stayed at the hospital and  started with antibiotics, enoxaparin, and oxygen, with a favourable clinical evolution. The doctor ordered a new X-ray but the patient started with dyspnea during his journey to the radiology department. Can you suggest a reason for that?

EVOLUTION: The patient was receiving oxygen to keep a normal blood saturation. Across the period of time invested in the transfer to the radiology department and back to the ward, he suffered hypoxemia because the oxygen cylinder was not properly checked.

ROOT-CAUSE ANALYSIS:

What happened?: No proper oxygen to the patient

Why this happens?: No good communication. No supervision of the procedure.

What can be done?: Always check the pressure of oxygen inside the cylinder.

FINAL ANALYSIS: Empty oxygen cylinder.