PENNGAS 2
Received Jul 25, 1997 · Event occurred Jul 18, 1997
Report 107570 · MDR key 107570
Device
Generic name
Compressed Gas N.o.s. 22
Manufacturer
Pennsylvania Engineering Co.Model number
UNKCatalog number
UNK
Lot number
UNK
Product problems
- Design/structure problem
- Gas Output Problem
- Leak/Splash
Patient
59 YR
- Overdose
- Contamination, chemical
Narrative
Description of Event or Problem
OTHER EMPLOYEE INADVERTANTLY OPENED THE EO/HCFC TANK VALVE AND VENT LINE, RELEASING THE TANK CONTENTS INTO THE DEPARTMENT. THIS EMPLOYEE WAS ABOUT 20 FEET AWAY AND EXITED IN THE OPPOSITE DIRECTION FROM WHERE THE TANK CONTENTS WERE BEING RELEASED.
Description of Event or Problem
OTHER EMPLOYEE INADVERTANTLY OPENED THE EO/HCFC TANK VALVE AND VENT LINE, RELEASING THE TANK CONTENTS INTO THE DEPARTMENT. THIS EMPLOYEE WAS ABOUT 10 FEET AWAY WHEN THE INCIDENT OCCURRED, BUT HAD TO GO THE IMMEDIATE AREA WHERE THE TANK CONTENTS WERE BEING RELEASED TO EXIT THE DEPARTMENT.
Description of Event or Problem
THE EMPLOYEE TURNED THE EO/HCFC TANK VALVE IN A COUNTERCLOCKWISE DIRECTION IN AN ATTEMPT TO CLOSE THE TANK IN ORDER TO CLEAN THE STERILIZER WHICH RESULTED IN THE TANK VALVE OPENING, NOT CLOSING AS EXPECTED. AS THE VENT LINE OPENED EO/HCFC WAS RELEASED INTO THE WORK AREA CREATING A GREATER THAN 200PPM EXPOSURE. THERE WAS NO CLARIFICATION THAT THE TANK VALVE WAS STANDARD RIGHT HAND THREAD AND THE HOSE CONNECTION REVERSE THREAD. AN ARROW ON THE TANK VALVE WAS NOT READILY VISIBLE BECAUSE OF THE FACT OF ITS SIZE AND THE COLOR, THE SAME COLOR AS THE TANK. THE TANK WAS FULL AND COMPLETELY EMPTIED.