BEUDAMED
    FDA Adverse Event Other Summary report: N

    OXYGEN GAS LINE

    MDR report key: 1431451 · Received July 30, 2009

    Report

    Report Number
    MW5012147
    Event Type
    Other
    Date Received
    July 30, 2009
    Date of Event
    June 22, 2009
    Report Date
    July 30, 2009
    Product Code
    ECX
    Report Source
    Voluntary report
    Reporter Location
    WA, US
    Reporter Occupation
    RISK MANAGER

    Narratives

    Description of Event or Problem · 1

    THIS EVENT OCCURRED IN THE NEWLY REMODELED OUTPATIENT ONCOLOGY INFUSION CENTER. IT WAS DETERMINED THAT THE LINE DESIGNATED FOR OXYGEN CONTAINED MEDICAL AIR. THE LINE DESIGNATED FOR MEDICAL AIR CONTAINED OXYGEN. PATIENT HAD COME FOR INFUSION SERVICES AND WAS REMOVED FROM HIS OWN OXYGEN TANK AND WAS PLACED ON WALL OXYGEN FOR THE INFUSION. HIS OXYGEN SATURATIONS DROPPED AND HE WAS PLACED ON AN OXYGEN TANK IN THE UNIT. HIS INFUSION WAS CONTINUED WITHOUT EVENT. THE BIOMEDICINE DEPARTMENT WAS CALLED AND THEIR STAFF COULD NOT DETERMINE ANY PROBLEM WITH THE GAUGES. THE NEXT DAY, RESPIRATORY THERAPY WAS CONTACTED AND DETERMINED THAT OXYGEN WAS NOT COMING OUT OF THE LINE FOR OXYGEN. DATES OF USE: 2009. EVENT ABATED AFTER USE STOPPED OR DOSE REDUCED?: NO. EVENT REAPPEARED AFTER REINTRODUCTION?: NO.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 OXYGEN GAS LINE NONE ECX MEDIAL GAS CER
    2 MEDICAL GAS LINE NONE ECX MEDICAL GAS CE

    Patients

    Seq Age Sex Outcome Treatment
    1 88 YR Other