Accidental cross-connexion of oxygen and nitrous oxide in an anaesthetic machine.
Oxygen and nitrous oxide pipes were cross-connected during the servicing of an anaesthetic machine. This resulted in the delivery of 100% nitrous oxide instead of 100% oxygen at the end of the operation. The patient fully recovered and was discharged on the 13th day.
D000059:Accidents; D000769:Anesthesia, Inhalation / Q000295:instrumentation*; D004868:Equipment Failure; D004869:Equipment Safety; D006801:Humans; D007223:Infant; D008297:Male; D009609:Nitrous Oxide; D010100:Oxygen
D009609:Nitrous Oxide; D010100:Oxygen