FLOW SELECTOR VALVE
Received Oct 4, 2005 · Event occurred Aug 19, 2005
Report 698700 · MDR key 698700
Device
Generic name
Respiratory Oxygen Gauge Valve
Manufacturer
Instrumentation Industries, Inc.Model number
SC 603-ACatalog number
*
Lot number
*
Product problems
- Markings, none
- Misplacement
- Replace
Patient
75 YR
- Low Oxygen Saturation
Narrative
Description of Event or Problem
PATIENT ADMITTED AND UNDERWENT OPEN HEART SURGERY. POST-UP, PATIENT WAS ON O2 NASAL CANNULA. PATIENT WAS TRANSFERRED FROM SICU TO N2W. PATIENT ASSISTED TO BED. O2 NASAL CANNULA CONNECTED TO GAUGE WITH TOGGLE SWITCH. THE TOGGLE SWITCH WAS NOTED TO BE IN THE INCORRECT POSITION AND THE O2 WAS NOTED TO BE IN THE INCORRECT POSITION AND THE O2 WAS NOT FLOWING TO THE PATIENT. THE PATIENT'S O2 WAS NOT FLOWING TO THE PATIENT. THE PATIENT'S O2 STATS DROPPED TO 50'S. PATIENT PLACED ON 100% NON-REBREATHER MASK AND TRANSFERRED BACK TO SICU FOR FURTHER TREATMENT. SWITCH IS NOT MARKED AND IS VERY CONFUSING TO USE.