Therapist’s Vigilance
Saves ICU Transfer Patient

Medical transports between hospitals happen every day, but this incident highlights how small details can become life-threatening if overlooked. Winnie Wong’s decision to question whether enough oxygen was available — and her insistence on bringing backup equipment — prevented what could have become a tragic outcome for both the patient and her unborn twins. The event also demonstrates how frontline healthcare workers can drive system-wide improvements that strengthen patient safety for future emergency transfers.

Respiratory Therapist’s Vigilance Protects Critically Ill Pregnant Patient During Interfacility Transfer

Winnie Wong’s intervention leads to new system-wide transport safety protocol

A respiratory therapist at NYC Health + Hospitals/North Central Bronx (NCB) has been honored for an act of clinical excellence that protected a critically ill pregnant patient during an interfacility transfer.

The episode, which unfolded during what could have been a routine transfer, became a demonstration of what happens when a culture of continuous learning exists within a healthcare facility.

The patient — eight weeks pregnant with twins and diagnosed with a severe pulmonary embolism — required supplemental oxygen. She was being transferred from North Central Bronx Hospital to NYC Health + Hospital/Jacobi when Wong, assisted by Respiratory Therapist Ketty Seide, moved forward.

“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.

The hospital’s leadership formally recognized Wong and Seide, honoring their professionalism along with the broader lesson their actions offer to the entire healthcare community.

“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.

Thanks to Wong’s intervention, North Central Bronx Hospital has implemented a mandatory checklist for oxygen and equipment for all ICU patients undergoing interfacility transfer.

“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 initiative has been recognized at the system level as a model of how frontline clinical excellence leads to institutional improvement.