Jove
Visualize
Contact Us
JoVE
x logofacebook logolinkedin logoyoutube logo
ABOUT JoVE
OverviewLeadershipBlogJoVE Help Center
AUTHORS
Publishing ProcessEditorial BoardScope & PoliciesPeer ReviewFAQSubmit
LIBRARIANS
TestimonialsSubscriptionsAccessResourcesLibrary Advisory BoardFAQ
RESEARCH
JoVE JournalMethods CollectionsJoVE Encyclopedia of ExperimentsArchive
EDUCATION
JoVE CoreJoVE BusinessJoVE Science EducationJoVE Lab ManualFaculty Resource CenterFaculty Site
Terms & Conditions of Use
Privacy Policy
Policies

Related Experiment Videos

Oxygen delivery failure resulting from interference with a Bain breathing system.

H Hay1

  • 1Department of Anaesthetics, Guy's Hospital, London, UK.

European Journal of Anaesthesiology
|October 12, 2000
PubMed
Summary

A critical incident occurred due to misconnecting an anesthesia breathing system valve, leading to a patient being deprived of fresh gas. This highlights the risks of unauthorized equipment modifications.

Related Concept Videos

You might also read

Related Articles

Articles linked to this work by shared authors, journal, and citation graph.

Sort by
Same author

Spinal anaesthetic with patient wearing enhanced combat body armour.

Journal of the Royal Army Medical Corps·2008
Same author

Contamination of piped medical gas supply with water.

European journal of anaesthesiology·2000
Same author

Delivery of an hypoxic gas mixture due to a defective rubber seal of a flowmeter control tube.

European journal of anaesthesiology·2000
Same author

Rapidly developing airway obstruction resulting from achalasia of the oesophagus.

European journal of anaesthesiology·2000
Same author

Studies on the specificity of the L929 cell bioassay for the measurement of tumour necrosis factor.

Journal of clinical & laboratory immunology·1989
Same author

Leukotrienes, LTC4 and LTB4, in bronchoalveolar lavage in bronchial asthma and other respiratory diseases.

The Journal of allergy and clinical immunology·1989

Area of Science:

  • Anesthesiology
  • Medical Device Safety

Background:

  • Bain-type breathing systems are common in anesthesia.
  • Obsolete equipment versions may pose unique risks.
  • Proper assembly of breathing circuits is crucial for patient safety.

Observation:

  • An expiratory port of an obsolete Bain-type valve was wrongly connected to the anesthetic machine's common gas outlet.
  • A plastic connector facilitated this critical misconnection.
  • The patient was deprived of fresh gas supply.

Findings:

  • The misconnection created a critical incident during anesthesia.
  • Unauthorized modifications to medical equipment can lead to dangerous situations.
  • Despite the error, the patient fortunately experienced no harm.

Related Experiment Videos

Implications:

  • Highlights the significant danger of unauthorized interference with anesthesia equipment.
  • Underscores the need for vigilance regarding equipment modifications and assembly.
  • Emphasizes the importance of using up-to-date and properly maintained medical devices.