Tottori Hospital technician forgot to connect the oxygen wire to the ECMO machine for 20 minutes, the patient's brain was seriously damaged

The technician's mistake of disconnecting the ECMO machine's oxygen supply for 20 minutes at Tottori Provincial General Hospital caused severe brain damage to the patient.

On September 1, the leader of Tottori Provincial General Hospital publicly apologized to the family of a male patient over 70 years old, after medical staff forgot to connect the oxygen supply line to the cardiopulmonary bypass system (ECMO), causing serious brain damage, according to Asahi Shimbun.

At the press conference, hospital Director Hiroki Chizumi admitted that the technician's operating errors directly caused medical complications. He confirmed that the unit lacks a cross-checking process between personnel when operating equipment, and committed to establishing an investigation council and being responsible to the patient's relatives. The victim, an office worker residing in Kanagawa Prefecture, became ill during a trip to Tottori and is currently in a deep coma.

The accident started on August 11 when the team transferred the patient from the Emergency Resuscitation Department to the cardiovascular intervention room to drain stagnant blood around the pericardium. To ensure safe movement, a male technician over 30 years old locked the valve on the portable compressed air tank. Upon arrival, this employee forgot to reconnect the air tube to the oxygen exchange membrane - the lung replacement part that withdraws carbon dioxide and pumps oxygen directly into the blood stream. The ECMO machine ran without oxygen for 20 minutes. The system sounded a warning bell about low blood oxygen levels four times, but the technician ignored it because "he was sure he had already connected the wire". Another doctor later discovered the problem and provided emergency care, but the diagnosis on August 12 confirmed that the patient had extensive cerebral edema.

Previously, on August 9, the patient was admitted to the emergency room with severe chest pain. The doctor determined that he had a blockage in the coronary artery that feeds the heart (myocardial infarction) and placed him on invasive ventilation. The worsening progression of respiratory failure forced the treatment team to prescribe ECMO intervention to support the heart and lungs. Technical errors at the transportation stage then erased the patient's chance of recovery.