An insidious failure of an oxygen analyzer.
We present a case of oxygen analyzer malfunction diagnosed by the failure of the patient to adequately breathe oxygen as measured by end-tidal oxygen concentration. A warning icon, compliant with international standards, was not noticed at the time by those involved in the patient's care. The role of effective medical device user interface design is discussed.
Harris
Bryan
B
Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee, USA.
Weinger
Matthew B
MB
D000368:Aged; D000768:Anesthesia, General / Q000295:instrumentation / Q000379:methods; D004868:Equipment Failure; D006801:Humans; D008297:Male; D016343:Monitoring, Intraoperative / Q000295:instrumentation* / Q000379:methods*; D010092:Oximetry / Q000295:instrumentation / Q000379:methods