A pt of advanced age had been on ventilation using an endotracheal tube and a ventilator for a period of treatment, and when extubation parameters were established the pt was successfully weaned from ventilation.The pt was breathing adequately post-extubation, but show signs of weakening efforts and became a candidate for re-intubation (an airway exchange catheter was not used during the trial of unassisted ventilation).During an emergency re-intubation of the pt, the physician trainee inserted the glidescope cobalt video baton 180 degrees off from the correct orientation into the gvl stat.This was contrary to the user manual instructions.When inserted correctly, the baton clicks into place, and the logos line up.The result of the incorrect baton insertion was difficulty with visualizing the airway on the monitor.The pt subsequently went into hypoxia-induced cardiac arrest, and expired.The icu director physician stated that the severe pt condition was the cause of death, and not the glidescope issue specifically.Ref # mfr 9615393-2014-00013.
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