Cause of Device-Related Incident
Device factors; External factors

Clinical Specialty or Hospital Department
Anesthesia; CCU / ICU / NICU; Clinical/Biomedical Engineering; Neonatology; Obstetrics and Gynecology; OR / Surgery; Pulmonary / Respiratory Therapy

Device Factors
Device failure; Improper maintenance, testing, repair, or lack or failure of incoming inspection

Document Type
User Experience Network (UEN) reports

External Factors
Medical gas and vacuum supplies

Mechanism of Injury or Death
Suffocation; Underdose

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated

UMDNS
Oxygen-Air Proportioners [12-876]

Inaccurate O2 Concentrations from Oxygen-Air Proportioners



User Experience Network™ [Health Devices Oct 1989;18(10):366-7]

Hospital

We have recently experienced incidents of inaccurate oxygen concentrations being measured from oxygen-air proportioners (blenders) in our neonatal intensive care unit (NICU). Does ECRI know what the cause of the problem might be?

ECRI

Inaccurate fractional index of oxygen (FIO2 ) readings could be caused by oxygen-air proportioners that are out of calibration and therefore do not deliver the preset concentration. The gas supply lines could be contaminated or not at optimal pressures for the proportioner. Another cause of inaccuracy is leaky check valves at the compressed gas inlets. We have found that many such problems have been reported when proportioners have been connected to inlets but not to patients. For example, higher-pressure oxygen can be forced into the medical compressed air pipeline if the check valve at the medical compressed air inlet is defective. When the proportioner is not connected to a patient, the path of least resistance for the higher-pressure oxygen is the piped air system. We recommend that any proportioning device be disconnected from the medical compressed gas line when not being used for patient care.

We also recommend that these devices, as well as inlet check valves built into these and other devices (e.g., ventilators, anesthesia machines), be inspected for accuracy, damage, and proper operation twice a year. Malfunctioning proportioners should be returned to the manufacturer for repair.

For further information, see our evaluation of oxygen-air proportioners in Health Devices 14(9):263-76, July 1985, and our Inspection and Preventive Maintenance Procedure in the Health Devices Inspection and Preventive Maintenance System manual.

UMDNS Term

Oxygen-Air Proportioners [12-876]

Cause of Device-Related Incident

Device factors: Device failure; Improper maintenance, testing, repair, or lack or failure of incoming inspection

External factor: Medical gas and vacuum supplies

Mechanism of Injury or Death

Suffocation; Underdose

 

 

 


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