Out of sight killers—the ongoing problem with hospital gas lines

Abstract

The recent death of one neonate and injury to another due to resuscitation with nitrous oxide and not oxygen highlights the continuing risk associated with the delivery of piped nitrous oxide into hospitals. The cause of this incident was not unique, with many identical deaths and injuries occurring frequently around the world over several decades. While standards and design focus are often directed at the equipment used by clinicians, attention also needs to be directed at developing safety mechanisms throughout an entire gas delivery process to prevent ongoing tragedies associated with gas-delivery errors.

Purity monitoring in medical gas supply lines with quantum cascade laser technology

“…The laser repet- itively tunes over a spectral range of 0.7 cm −1 via a monotonic current ramp with a repetition rate of 2 kHz. To reduce the heat impact of the laser and allow it to reliably achieve the laser temperature of 7 • C via Peltier cooling, the intermittent scanning regime introduced by Fischer is applied (Fischer et al, 2014). A duty cycle of 20 % is selected.…”

Medical Gas Systems Maintainability Risks in Healthcare Facilities: A Design Optimization Approach

“…Previous research on MGPSs have investigated the risks that may arise from the operation and maintenance of healthcare facilities. Anesthetic practitioners, clinical engineers, and safety practitioners reported several cases of deaths and injuries, fires, and near-misses that originate from the use of MGPSs [7,27,29,45,46]. While design-caused maintenance issues need further studies, it has been established that design errors lead to cost and performance impacts [10,12,32,33,41,47].…”

“…Unfortunately, design errors may occur in an MGPS, which can be hidden even after construction [6]. Although precautionary measures are advised, death by accident by cross-connecting gasses continues to occur, and this requires a failsafe design methodology [7,8]. A certain study has urged healthcare facilities to optimize the management of MGPSs for capital savings and environmental reasons [3].…”