[Failure of operating room oxygen delivery due to a structural defect in the ceiling column]

Two operating rooms were newly constructed to facilitate the increasing need of surgical services in our university hospital. After a half year of use, the oxygen delivery was suddenly blocked in one of them. Fortunately, the serious incident did not occur because an anesthesiologist identified the blockage of oxygen flow when he checked the anesthesia machine prior to the patient arriving in the operating room. Upon investigation we found the structural defects in ceiling column of that operating room. The pipe containing nitrous oxide and its structural support touched the valve of oxygen supply. It appears that the valve was gradually turned off by this contact while the ceiling column was moved up and down. Once this structural defect had been repaired, there was no longer any incident of the accidental blockage of oxygen to the operating room.