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Medical Gas Mix-Up Deaths

FDA Patient Safety News – February, 2002 – Show #1 The FDA issued a warning about patient injuries and deaths from mix-ups with medical gases that come in cryogenic containers.


Anita Rayner, Associate Policy Director, FDA: The FDA (Food and Drug Administration) recently issued a warning about the possibility of patient injuries and deaths from mix-ups with medical gases, particularly oxygen, that come in cryogenic containers. We issued the warning because we've received a number of reports of deaths and injuries that occurred when patients were accidentally given the wrong gas. That is, another gas, like nitrogen or carbon dioxide, was connected to the oxygen supply system. That occurred despite the fact that the gas supply systems that deliver gas to patients have special connectors that only fit the appropriate gas containers. That means that an oxygen container will only fit onto the oxygen connector on the gas supply system. So there's supposed to be a built-in safeguard. But in these cases, this safeguard was bypassed and a gas other than oxygen was mistakenly hooked up to the oxygen connector on the supply system and then delivered to the patient. Considering this safeguard, what went wrong?
Mark Barnett, Communications Director, FDA: In the cases we looked at, two errors were usually made in sequence. First, in most of the cases, a container of gas other than oxygen was mistakenly delivered to the facility, and sometimes it was misidentified as containing oxygen. Then someone tried to connect this gas container - the one they thought contained oxygen - to the oxygen supply system. Of course this didn't work, because of the safeguard we talked about. And so they then overrode the safeguard by changing the connector on the gas container so it would fit the oxygen connector on the gas delivery system.
AR: There are things you can do to prevent such things from happening.
MB: First of all, never use adapters or change the connectors or the fittings on gas containers. If a connector on a container won't readily attach to the connector on your gas supply system, it's probably the wrong gas. Don't try to connect it!
AR: Second, when connecting a medical gas container, check the label carefully to ensure that it contains the right gas.
MB: Third, be sure that all personnel who handle medical gases are properly trained to examine and recognize medical gas labels.
AR: Finally, if your facility receives both medical and industrial grade gases, store them separately.

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