BEUDAMED
    FDA Adverse Event Other Summary report: N

    OXYGEN TANK

    MDR report key: 1303345 · Received January 22, 2009

    Report

    Report Number
    MW5009840
    Event Type
    Other
    Date Received
    January 22, 2009
    Date of Event
    December 30, 2008
    Report Date
    January 12, 2009
    Manufacturer
    AOC
    Product Code
    BYJ
    Report Source
    Voluntary report
    Reporter Location
    TX, US
    Reporter Occupation
    NURSE

    Narratives

    Description of Event or Problem · 1

    RADIOLOGY AND RESPIRATORY STAFF WERE SETTING UP AN MRI ROOM FOR A VENTILATOR PATIENT AS SCHEDULED. AS REPORTED PER RADIOLOGY, UPON ENTERING THE ROOM, THE VENT TORQUED AND RESPIRATORY TECH WAS UNABLE TO HOLD IT BACK ON HIS OWN. HE WAS ASSISTED BY TWO OTHER PEOPLE IN THE ROOM, MOVING IT AWAY FROM THE BORE OF MRI UNIT DIRECTION. UPON INSPECTION OF O2 (OXYGEN) TANK, IT WAS FOUND THAT THE TANK WAS PAINTED GRAY LIKE ALUMINUM WHICH WOULD HAVE BEEN COMPATIBLE WITH MRI UNIT. PER MANUFACTURER UPON NOTIFICATION, INSPECTION OF CYLINDERS WAS CARRIED OUT AND CONSIDERED THIS AN ISOLATED INCIDENT. HOWEVER, THEY MENTION IMPLANTATION OF ADDITIONAL TRAINING FOR ALL STAFF MEMBERS ASSOCIATED WITH FILLING, TRANSPORTING, HANDLING THE DELIVERY OF MEDICAL GAS CYLINDERS. AS FOR OUR HOSPITAL, RECOMMENDATION WAS MADE TO CONSIDER A SUPPLY OF ONLY ALUMINUM TANKS TO AVOID FUTURE INCIDENTS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 OXYGEN TANK OXYGEN TANK BYJ AOC 90L10C59

    Patients

    Seq Age Sex Outcome Treatment
    1