inforMED
MalfunctionBXY

OHMEDA QUICK CONNECT

Received Sep 21, 2012 · Event occurred Jul 19, 2012

Report 2843524 · MDR key 2843524

Device

Generic name

Flowmeter, Calibration, Gas, Adapter

Manufacturer

Cardinal Health

Model number

*

Catalog number

539-2105

Lot number

*

Product problems

  • Improper or Incorrect Procedure or Method
  • Inaccurate Delivery
  • Component or Accessory Incompatibility

Patient

65 YR

  • No Information

Narrative

Description of Event or Problem

PATIENT WAS CONNECTED TO MEDICAL AIR AND NOT OXYGEN. WE USE PISS (PIN INDEX SAFETY SYSTEM) FLOWMETERS IN THE NEWER AREAS OF THE HOSPITAL AND DISS(DIAMETER INDEX SAFETY SYSTEM) FLOWMETERS IN THE OLDER WINGS. EITHER WAY YOU MAY NOT PLUG AN OXYGEN FLOWMETER INTO AN AIR OUTLET OR VICE VERSA. THE NIPPLE ADAPTER THAT IS USED TO ATTACH A DELIVERY DEVICE (E.G. MASK, NASAL CANNULA) IS THE SAME SIZE. WE HAVE GREEN/YELLOW COLOR CODED NIPPLES WHICH ARE INTERCHANGEABLE. THE PROBLEM ARISES WHEN STAFF PLACES THE INCORRECT NIPPLE ONTO THE FLOWMETER AND ASSUMES THAT THE NIPPLE COLOR DENOTES THE DELIVERED GAS.