inforMED
MalfunctionCAM

CO2 CONNET 2 CHEMETRON OUTLET

Received Jan 23, 2009 · Event occurred Nov 13, 2008

Report 1924066-2009-00001 · MDR key 1342634

Device

Generic name

Co2 Outlet Station

Model number

64-02-5007

Catalog number

64-02-5007

Lot number

UNKNOWN

Product problems

  • Connection Problem

Patient

Not reported

  • No Patient Involvement

Narrative

Description of Event or Problem

IT WAS REPORTED THAT THE HOSPITAL USING WALL PROVIDED N2O AND CO2 GAS HAD A PROBLEM. THE HOSPITAL WAS ABLE TO PLUG THE N2O OHIO DIAMOND CONNECTOR INTO THE CHEMETRON MODEL 500 CONNECT 2 N2O OUTLET, WHICH IT IS INTENDED FOR, BUT ALSO INTO THE CO2 OUTLET, WHICH IT IS NOT INTENDED FOR. THE OHIO DIAMOND CONNECTOR FOR CO2 DOES NOT FIT IN ANY OTHER GAS OUTLET. THE OUTLETS ARE DESIGNED TO ACCEPT EITHER A CHEMETRON OR OHIO DIAMOND CONNECTOR. LABELING THE CONNECTORS WILL NOT HELP, AS THE PROBLEM CAN STILL OCCUR IF THE CONNECTOR IS TURNED OVER AND INSERTED INTO THE WALL OUTLET. WE PLAN TO CHANGE THE N2O CONNECTOR FROM OHIO DIAMOND TO CHEMETRON ON ALL ANESTHESIA MACHINES. THE CHEMETRON FITTING FOR N2O CAN NOT FIT INTO THE CO2 WALL OUTLET.

Additional Manufacturer Narrative

CONNECT 2 OUTLETS ARE LABELED FOR THE GAS THEY ARE INTENDED FOR. (CARBON DIOXIDE). CONNECT 2 OUTLETS ARE COLOR CODED FOR THE GAS THEY ARE INTENDED FOR. (GRAY FOR CARBON DIOXIDE). THE ONLY WHAT TO MAKE AN OHIO N2O ADAPTER GO INTO A CHEMETRON CO2 CONNECT 2 OUTLET IS TO TURN IT UPSIDE DOWN (180 DEGREES).