Abstract:Intraoperative hypoxia occurred in two patients during the maintenance of the medical gas system. Engineers were purging oxygen pipelines with nitrogen to remove particulate debris but were unaware of a connection to operating room pipelines. This case illustrates the importance of communication between anesthesia providers and engineers servicing the gas system.
“…Cross over of gas pipelines,[23] filling of cylinders with wrong gases,[17] wrong connectors,[24] incorrect tanks from the central manifolds,[25] accidents during installation or routine maintenance of pipelines,[26] may all compromise patient safety.…”
Anaesthesia is one of the few sub-specialties of medicine, which has quickly adapted technology to improve patient safety. This application of technology can be seen in patient monitoring, advances in anaesthesia machines, intubating devices, ultrasound for visualisation of nerves and vessels, etc., Anaesthesia machines have come a long way in the last 100 years, the improvements being driven both by patient safety as well as functionality and economy of use. Incorporation of safety features in anaesthesia machines and ensuring that a proper check of the machine is done before use on a patient ensures patient safety. This review will trace all the present safety features in the machine and their evolution.
“…Cross over of gas pipelines,[23] filling of cylinders with wrong gases,[17] wrong connectors,[24] incorrect tanks from the central manifolds,[25] accidents during installation or routine maintenance of pipelines,[26] may all compromise patient safety.…”
Anaesthesia is one of the few sub-specialties of medicine, which has quickly adapted technology to improve patient safety. This application of technology can be seen in patient monitoring, advances in anaesthesia machines, intubating devices, ultrasound for visualisation of nerves and vessels, etc., Anaesthesia machines have come a long way in the last 100 years, the improvements being driven both by patient safety as well as functionality and economy of use. Incorporation of safety features in anaesthesia machines and ensuring that a proper check of the machine is done before use on a patient ensures patient safety. This review will trace all the present safety features in the machine and their evolution.
“…1 The quality standards and the safety features in the modern anesthesia workstations further reduce any error in delivering anesthetic gases to the patient. [3][4][5][6] We report influx of water into the flowmeter assembly of an anesthesia work station (GE Datex Ohmeda Aestiva/5; GE Healthcare, Madison, WI) during the administration of general anesthesia. [3][4][5][6] We report influx of water into the flowmeter assembly of an anesthesia work station (GE Datex Ohmeda Aestiva/5; GE Healthcare, Madison, WI) during the administration of general anesthesia.…”
SummaryNitrous oxide continues to be used frequently and the possibility of inadvertent fatal hypoxaemia resulting from technical errors with its administration still exists. A Medline analysis revealed only a few case reports over the last 30 years, and a closed claim analysis only reported ‘claims involving oxygen supply lines’ predating 1990. The aim of this study was to assess the frequency of nitrous oxide‐related catastrophes during general anaesthesia in Germany, Austria, and Switzerland. As nitrous oxide‐related anaesthesia casualties are rare but generally prosecuted, they almost invariably attract significant media attention. We scanned mass media archives from April 2004 until October 2006 for nitrous oxide‐related disasters during general anaesthesia. This approach detected six incidents which were almost certainly nitrous oxide ventilation‐related deaths. Searching non‐scientific data bases demonstrates that severe incidents involving oxygen supply lines occurred after 1990, and may be much more frequent than previously thought.
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