Cause of Device-Related Incident*Not stated
Clinical Specialty or Hospital DepartmentAnesthesia; OR / Surgery; Pulmonary / Respiratory Therapy
Device Factors*Not stated
External Factors*Not stated
Mechanism of Injury or DeathFailure to deliver therapy; Suffocation
Support System Failures*Not stated
Tampering and/or Sabotage*Not stated
User Errors*Not stated
Use Special Care with Disposable Anesthesia Patient Circuits
To prevent disconnects, use force and wringing to attach all hoses
Check that Y-piece connections of the circuit are forced on
Arrange hoses carefully around and over equipment. They kink and
occlude more easily than reusable hoses.
Be sure the hoses are well clear of the surgical field if an ESU or
cautery unit is to be used. They are easily ignited by a concentrated
Choose conductive circuits only if they are to be used in a
flammable anesthetic area.
Do not grip swivel units too tightly, even though they may snap back
together again after popping out of their sockets, because leakage may
Check system leakage before and after attaching the patient circuit.
If the circuit adds excessive leakage, do not use it. Use a new patient
circuit instead, and check again for system