Cause of Device-Related Incident
Device factors; External factors; Support system failures; User errors

Clinical Specialty or Hospital Department
Anesthesia; Cardiology / Cardiac Catheterization; Clinical/Biomedical Engineering; Emergency Medicine; Facilities Engineering; Obstetrics and Gynecology; OR / Surgery; Pulmonary / Respiratory Therapy

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

Document Type
Hazard Reports

External Factors
Medical gas and vacuum supplies; Power supply (including piped medical gases)

Mechanism of Injury or Death
Overdose; Suffocation; Underdose; Wrong drug

Support System Failures
Lack or failure of incoming and pre-use inspections

Tampering and/or Sabotage
*Not stated

User Errors
Accidental misconnections; Failure to perform pre-use inspection; Improper connection

UMDNS
Anesthesia Units [10-134]; Fittings/Adapters, Pneumatic, Quick Connect [11-731]

Nitrogen Distribution Systems



Hazard [Health Devices Feb 1989;18(2):85]

Problem

A member hospital reported that after installation of a new anesthesia machine equipped to use oxygen, nitrous oxide, and air, pre-use tests of the unit produced no airflow through the unit until one of the OR personnel turned on the regulator on a wall-mounted nitrogen control panel installed for the use of nitrogen-powered tools. What appeared to be airflow was then determined to be nitrogen. Delivery of such a hypoxic gas component to a patient would be a serious risk.

Discussion

The nitrogen panel controlled the distribution of nitrogen to a ceiling track assembly fitted with nitrogen delivery hoses. Both the nitrogen panel and its hoses were fitted with a specific brand of air fittings.

When the system was installed, the panel manufacturer offered a choice of DISS nitrogen and two brand-name fittings. The hospital's existing anesthesia units did not use air and consequently had no air inlet fittings that might permit misconnection to a nitrogen outlet. Therefore, because there were no quick-connect brand-name nitrogen fittings available at the time, the hospital chose to use quick-connect brand-name air fittings in the nitrogen system.

Hospitals should update systems with proper gas-specific wall, hose, and equipment fittings to prevent nitrogen/air misconnections.

Recommendations

  1. Inspect all high-pressure nitrogen systems to be sure they have only nitrogen-specific fittings. Compressed air fittings marked for nitrogen are still unsafe because they can be misconnected accidentally. Include in your inspection all wall or ceiling outlets, hoses (both ends), and equipment to which these supplies may be connected. Replace any inappropriate fittings with those that are nitrogen-specific. We recommend DISS fittings, but some users prefer quick-connect fittings for the tool itself. Even if connector-equipment mismatches are unlikely now, they are likely to be a problem in the future.
  2. Until new fittings can be installed, tag affected outlets and units to alert users to possible misconnection.
  3. Inspect all gas systems at the time of installation, following repairs, and periodically. (See Health Devices Inspection and Preventive Maintenance System procedure for Medical Gas/Vacuum Systems (440-595).

UMDNS Terms

  • Anesthesia Units [10-134] 
  • Fittings/Adapters, Pneumatic, Quick Connect [11-731]

Cause of Device-Related Incident

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

User errors: Accidental misconnections; Failure to perform pre-use inspection; Improper connection

External factors: Medical gas and vacuum supplies; Power supply

Support system failure: Lack or failure of incoming and pre-use inspections

Mechanism of Injury or Death

Overdose; Suffocation; Underdose; Wrong drug


[Home]    [About]    [Help]    [Site Map]
Copyright © 2017 ECRI
All rights reserved
www.ecri.org