Cause of Device-Related Incident
*Not stated

Clinical Specialty or Hospital Department
Anesthesia; OR / Surgery; Pulmonary / Respiratory Therapy

Device Factors
*Not stated

Document Type

External Factors
*Not stated

Mechanism of Injury or Death
Failure 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 and fittings.
  • Check that Y-piece connections of the circuit are forced on firmly.
  • 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 heat source.
  • 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 increase.
  • 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 leakage.

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