inforMED
DeathBYP

ONE WAY VALVE

Received Sep 2, 2016 · Event occurred Aug 24, 2016

Report 5935417 · MDR key 5935417

Device

Generic name

One Way Valve

Manufacturer

Ge

Product problems

  • Connection error
  • Connection Problem
  • Connection error

Patient

46 YR

  • Death
  • Death

Narrative

Description of Event or Problem

MANUAL VENTILATION OF A PATIENT IN MRI SUITE WITH AMBU BAG, CORRUGATED TUBING AND ONE WAY VALVE. THE ONE WAY VALVE ASSEMBLE BETWEEN THE CORRUGATED TUBING AND THE ENDOTRACHEAL TUBE DID NOT ALLOW FOR EXHALATION. THE PATIENT EXPERIENCED CARDIOPULMONARY ARREST AND EXPIRED.