Cause of Device-Related Incident
Device factors; External factors

Clinical Specialty or Hospital Department
Clinical/Biomedical Engineering; Continuing Care; CSR / Materials Management; Home Healthcare; Nursing

Device Factors
Device interaction

Document Type
User Experience Network (UEN) reports

External Factors
Medical gas and vacuum supplies

Mechanism of Injury or Death

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated

Medical Gas Cylinders [16-501]; Wheelchairs, Powered [16-214]

Safe Use of Supplemental Oxygen with Powered Wheelchairs

User Experience Network™ [Health Devices Aug 1992;21(8):291]


A major wheelchair manufacturer told us not to use an oxygen cylinder (E-cylinder) with its powered wheelchair. We are concerned that such use presents a risk of fire for our patients who use powered wheelchairs and supplemental oxygen. What is an appropriate policy?


We have been investigating the risks of an oxygen-enriched atmosphere (OEA) near ignition sources (e.g., electric motors, surgical lasers) for many years; however, we know of no standards that directly address the use of oxygen cylinders with powered wheelchairs. The National Fire Protection Association standard addressing the use of electrical equipment during oxygen administration (NFPA 99, Section 7-6.2.3, 1990 edition) limits equipment use only within 1 ft of the "site of intentional expulsion" of the oxygen. The electrical components of the wheelchair, with the exceptions noted below, would be at least 1 ft from the patient's face. Although chin-operated joysticks and some switches may be within this distance, these components are not hot electrically or to the touch. Therefore, the use of a D- or E-cylinder of pressurized oxygen with a powered wheelchair is reasonably safe—provided that the cylinder is secured and protected (i.e., the cylinder is immobilized so that the stem and regulator cannot be bumped or broken off) and the oxygen is not allowed to accumulate under the patient's clothing or wheelchair upholstery or near the electric controls, motors, or battery compartments.

Hospitals and their patients who use powered wheelchairs should follow these guidelines whenever using supplemental oxygen:

  • Never smoke. Oxygen greatly increases the ignitability and flammability of surrounding fuels (e.g., hair, clothing, carpets).
  • Be sure that the oxygen cylinder is secured to the wheelchair and protected from inadvertent collisions, positioning the stem and regulator so that they will not be accidentally bumped. Any bumping or movement of the cylinder could damage the regulator, valves, or tubing and cause an oxygen leak, permitting oxygen accumulation.
  • Never charge or replace the wheelchair batteries. Both activities carry a high risk of producing an electric spark, which could lead to a flash fire or explosion in an OEA.
  • Be sure that the oxygen line is not draped near moving components of the wheelchair, especially near a powered recliner. This may lead to entangled tubing (leading to patient injury), leaks in the oxygen line, or damage to the wheelchair.
  • Check the oxygen tubing daily, from the cylinder to the delivery site, for leaks.
  • Turn off the oxygen source if the mask or cannula is not in use.

Strictly following these guidelines should safely allow the use of oxygen with powered wheelchairs.


  • Medical Gas Cylinders [16-501]
  • Wheelchairs, Powered [16-214]

Cause of Device-Related Incident

Device factor: Device interaction

External factor: Medical gas and vacuum supplies

Mechanism of Injury or Death


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