ACCUTRON
Received Dec 2, 2002 · Event occurred Oct 1, 2002
Report MW1026863 · MDR key 430489
Product problems
- Misassembled
- Other (for use when an appropriate device code cannot be identified)
Patient
*
- Unknown (for use when the patient's condition is not known)
Narrative
Description of Event or Problem
AN INCIDENT OCCURRED IN THE OFFICE WITH A N2O-O2 UNIT THAT WAS RECENTLY INSTALLED. THE PIPES WERE CROSSED IN THE WALLS. DENTIST WAS GIVING PATIENTS 100% N2O WHEN THEY THOUGHT THEY WERE GIVING THEM 100% O2. THE PROBLEM WAS COMPOUNDED BY THE USE OF A FLAVORED MASK. THE SCENT INTERFERED WITH THE CHARACTERISTIC ODOR OF N2O. DENTIST COULD NOT SMELL THE ODOR OF N2O. THEY COULD ONLY SMELL THE SCENT FROM THE FLAVORED MASK.