Gas Delivery Mistakes Continue to Kill

Robert C. Morell, MD

Two recent deaths occurring at a New Haven, Connecticut, hospital serve as a painful reminder that pipeline and gas delivery errors continue to occur with lethal consequences. In these particular cases an oxygen flow meter was altered by the removal of an index pin, allowing it to be connected to a wall source of nitrous oxide. These events took place in a cardiac catheterization suite, reminding us that pipeline and gas delivery errors can occur outside of the operating room, perhaps more easily than within the operating room, since oxygen analyzers are frequently not part of the monitoring modality. Both the New York Times and Anesthesia Malpractice Prevention have highlighted these events. Clearly the hazards of modifying gas delivery connections and altering indexed safety systems must be widely publicized, not just to anesthesiologists. Hospital administrators, medical gas contractors, and physicians and nurses involved in conscious sedation suites and the delivery of supplemental oxygen must be educated as to the risks and lethal consequences of tampering with medical gas connections.

The FDA issued an advisory in July 2001 to hospitals and nursing facilities calling attention to the hazards and injuries that can result from medical gas misconnects. Specifically, the FDA received reports of 15 deaths and 7 injuries linked to misconnects. The FDA has an internet advisory currently available at www.fda.gov/cdrh/safety/medical-gas-misconnect.html that targets the potential for improper connections of cryogenic medical gas vessels containing gasses other than oxygen to oxygen delivery systems. The Safe Medical Devices Act of 1990 requires hospitals and nursing facilities to report deaths or serious injuries associated with medical devices, including medical gas delivery systems. Reports can be made to the device or gas manufacturer or the the FDA’s MedWatch program at 1-800-FDA-1088 or online at www.accessdata.fda.gov/scripts/medwatch.