[Wrong connection of a flexible medical air hose to a nitrous oxide outlet caused by a defective safety device].
When plugging the O2, N2O and air hoses into the corresponding wall sockets, the air hose was wrongly inserted into the N2O wall outlet. This was made possible because of faulty retaining clasps of the male coupler of the air probe. French "fail-safe" connections consist of a two-clasp male coupler for air, three clasps for O2 and four clasps for N2O hoses. Additionally the clasps of the air probe are broader then those of the N2O probe. However, the latter difference was lost due to wear. The incident was recognized without delay as the N2O hose could not be inserted into the air outlet. However, it could have remained unnoticed had there been two N2O wall outlets and could have resulted in severe adverse effects.
Nicaise
C
C
Polyclinique de l'Espérance, Angers, France.
Robert
C
C
Ancellin
J
J
Cazalaà
J B
JB
D004868:Equipment Failure; D006801:Humans; D009609:Nitrous Oxide / Q000008:administration & dosage
D009609:Nitrous Oxide