BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    OHMEDA QUICK CONNECT

    MDR report key: 2843524 · Received September 21, 2012

    Report

    Report Number
    2843524
    Event Type
    Malfunction
    Date Received
    September 21, 2012
    Date of Event
    July 19, 2012
    Report Date
    September 21, 2012
    Manufacturer
    CARDINAL HEALTH
    Product Code
    BXY
    Product Problem
    Yes
    Report Source
    User Facility report
    Reporter Location
    CA, US

    Narratives

    Description of Event or Problem · 1

    PATIENT WAS CONNECTED TO MEDICAL AIR AND NOT OXYGEN. WE USE PISS (PIN INDEX SAFETY SYSTEM) FLOWMETERS IN THE NEWER AREAS OF THE HOSPITAL AND DISS(DIAMETER INDEX SAFETY SYSTEM) FLOWMETERS IN THE OLDER WINGS. EITHER WAY YOU MAY NOT PLUG AN OXYGEN FLOWMETER INTO AN AIR OUTLET OR VICE VERSA. THE NIPPLE ADAPTER THAT IS USED TO ATTACH A DELIVERY DEVICE (E.G. MASK, NASAL CANNULA) IS THE SAME SIZE. WE HAVE GREEN/YELLOW COLOR CODED NIPPLES WHICH ARE INTERCHANGEABLE. THE PROBLEM ARISES WHEN STAFF PLACES THE INCORRECT NIPPLE ONTO THE FLOWMETER AND ASSUMES THAT THE NIPPLE COLOR DENOTES THE DELIVERED GAS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 OHMEDA QUICK CONNECT FLOWMETER, CALIBRATION, GAS, ADAPTER BXY CARDINAL HEALTH * *
    2 OHMEDA QUICK CONNECT AIR FLOWMETER, CALIBRATION, GAS, CONNECTOR BXY CARDINAL HEALTH * *
    3 PRECISION MEDICAL 02 FLOW METER FLOWMETER, CALIBRATION, GAS, ADAPTER BXY CARDINAL HEALTH * *
    4 * FLOWMETER, CALIBRATION, GAS, ADAPTER BXY CAREFUSION * *

    Patients

    Seq Age Sex Outcome Treatment
    1 65 YR