title: [Fatalities due to nitrous oxide. Complications from mistakes in nitrous oxide supply].
abstract: Despite inspiratory oxygen fraction measurement being regulated by law in the European norm EN 740, fatal errors in nitrous oxide delivery still occur more frequently than expected, especially after construction or repair of gas connection tubes. Therefore, if nitrous oxide is to be used further in a hospital, all technical measures and system procedures should be employed to avoid future catastrophes. Among these are measurement of the inspiratory oxygen fraction (F(I)O(2)) and an automatic limitation of nitrous oxide. Also all anaesthetists involved should be informed about repair or construction of central gas supply tubes. Additionally, more awareness of this problem in daily routine is necessary. Furthermore, a system of detecting and analysing errors in anaesthesia has to be improved in each hospital as well as in the anaesthesia community as a whole. Measures for a better "error culture" could include data exchange between different critical incident reporting systems, analysis of closed claims, and integration of medical experts in examination of recent catastrophes.
authors: Universitätsklinik für Anästhesiologie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstr. 35, 6020 Innsbruck, Osterreich. holger.herff@uki.at
authors: H
authors: H
authors: Herff
authors: P
authors: P
authors: Paal
authors: K H
authors: KH
authors: Lindner
authors: A
authors: A
authors: von Goedecke
authors: C
authors: C
authors: Keller
authors: V
authors: V
authors: Wenzel
mesh_terms: D000769:Anesthesia, Inhalation / Q000401:mortality*; D000776:Anesthesiology / Q000295:instrumentation; D018685:Anesthetics, Inhalation / Q000008:administration & dosage / Q000009:adverse effects*; D004868:Equipment Failure; D006801:Humans; D007345:Insurance Claim Review; D007431:Intraoperative Complications / Q000139:chemically induced* / Q000401:mortality* / Q000517:prevention & control; D019300:Medical Errors; D016343:Monitoring, Intraoperative; D009609:Nitrous Oxide / Q000008:administration & dosage / Q000009:adverse effects*; D010100:Oxygen / Q000008:administration & dosage; D013647:Task Performance and Analysis
chemical_list: D018685:Anesthetics, Inhalation; D009609:Nitrous Oxide; D010100:Oxygen