NYC News Network | Local News Across New York City
A respiratory therapist at NYC Health + Hospitals/North Central Bronx is being recognized after her quick thinking helped prevent a potential oxygen emergency during the transfer of a critically ill pregnant patient. The incident has since prompted the hospital to introduce a mandatory ICU transport safety checklist, highlighting how frontline clinical vigilance can lead to system-wide patient safety improvements across New York City hospitals.
A routine hospital transfer in the Bronx has led to a system-wide safety change across NYC Health + Hospitals after a respiratory therapist’s decision to question standard procedure helped prevent a potential oxygen emergency involving a critically ill pregnant patient.
The incident, now formally recognized within the system, has resulted in a mandatory ICU transport checklist designed to prevent similar risks during interfacility transfers.
Details surrounding the announcement were first published in an official NYC Newswire press release. This outlines the city’s latest actions, policy details, and statements from officials.
Medical transfers between hospitals occur daily across New York City. However, during one ICU transfer from NYC Health + Hospitals/North Central Bronx to NYC Health + Hospital/Jacobi, a critical oversight risk was identified before it could escalate.
The patient, eight weeks pregnant with twins and diagnosed with a severe pulmonary embolism, required continuous oxygen support.
During preparation, respiratory therapist Winnie Wong raised a concern about whether enough oxygen would be available for the transfer.
“From past experience, I knew that at very high flow, tanks go through oxygen super quickly. So I said, I’m just going to go with you with a full tank and an Ambu bag,” said Winnie Wong, Respiratory Therapist, NYC Health + Hospitals/North Central Bronx.
That decision proved pivotal.
Wong’s insistence on bringing backup oxygen equipment ensured the patient remained stable throughout transport. Her actions, supported by Respiratory Therapist Ketty Seide, helped prevent a situation that hospital staff later described as potentially life-threatening.
Hospital leadership emphasized that the intervention was not about protocol failure alone, but about awareness in high-risk environments.
“In high reliable organizations, one of the things that allows people to succeed is when you focus on the possibility of failure, not being complacent. She used her lived experience of what could possibly go wrong. And unbeknownst to her, she taught that EMT something he will never forget,” said Dr. Chinyere Anyaogu, Deputy Chief Medical Officer, NYC Health + Hospitals/North Central Bronx.
Following the incident, NYC Health + Hospitals/North Central Bronx implemented a mandatory ICU transport checklist focused on oxygen readiness and equipment verification.
The change reflects how frontline clinical decisions can directly influence hospital policy and patient safety systems.
“Winnie asked such a simple question in such a non-threatening way: ‘Do you have enough oxygen?’ And then she was persistent. She had a gut feeling, and she didn’t let it go. This led to a mandatory checklist for all patients being transported from the ICU. She transformed something that was not so awesome into something very positive,” said Heidi Baer, Patient Safety Officer, NYC Health + Hospitals/North Central Bronx.
The checklist is now being recognized internally as a model for improving transport safety protocols across facilities.
The new protocol focuses on preventing oxygen shortages during high-risk transfers, particularly for patients requiring continuous respiratory support.
Key safeguards include:
Hospital officials say the goal is to reduce variability in emergency transfers and ensure consistent safety standards.
This case highlights a broader issue in hospital systems: small procedural gaps can escalate into life-threatening emergencies without careful oversight.
It also demonstrates how frontline healthcare workers often identify risks before formal systems do, reinforcing the importance of clinical experience in shaping hospital safety policies.
The intervention has been recognized internally as an example of how individual vigilance can trigger institutional improvement.
What is Therapist’s Vigilance in this case?
It refers to a respiratory therapist’s decision to question oxygen readiness during an ICU transfer, preventing a potential emergency.
What changed after the incident?
NYC Health + Hospitals introduced a mandatory ICU transport checklist focused on oxygen safety and equipment verification.
Why was the patient at risk?
The patient required high-flow oxygen during transfer, which can be depleted quickly without proper backup planning.
Get the latest updates on NYC policy, government decisions, housing, labor, and citywide developments delivered directly to your inbox.
Subscribe and join our newsletter to stay ahead of NYC’s biggest political stories.