BEUDAMED
    FDA Adverse Event Injury Summary report: N

    CARBON DIOXIDE TANK

    MDR report key: 597155 · Received April 3, 2005

    Report

    Report Number
    597155
    Event Type
    Injury
    Date Received
    April 3, 2005
    Date of Event
    March 25, 2005
    Report Date
    April 3, 2005
    Manufacturer
    COYNE
    Product Code
    ECX
    Adverse Event
    Yes
    Report Source
    User Facility report
    Reporter Location
    SC, US
    Reporter Occupation
    RISK MANAGER

    Narratives

    Description of Event or Problem · 1

    A CO2 TANK WITH A FLOWMETER ATTACHED, USED IN THE OPEN HEART ROOM WAS BROUGHT TO THE OR, ALONG WITH A TRANSPORT MONITOR BY RN. THE TANK WAS PLACED ON THE BED. THE CIRCULATING RN USED THE SAME KEY THAT WOULD BE USED TO OPEN AN OXYGEN TANK CYLINDER VALVE TO OPEN THE CYLINDER VALVE OF THE CO2 TANK. THE PATIENT WAS CONNECTED TO THE CO2 TANK. PT WAS TRANSFERRED TO THE ICU. AT THE END OF THE ELEVATOR RIDE, THE PATIENT BECAME BRADYCARDIC 30-40'S AND O2 SAT DROPPED TO 84%. THE PATIENT WAS RUSHED TO ICU AT WHICH POINT THE PT DETERIORATED TO PULSELESS ARREST. A CODE WAS BEGUN, MEDICATIONS GIVEN. AT THAT TIME, THE RESPIRATORY THERAPIST NOTICED THAT THE AMBU CIRCUIT WAS CONNECTED TO A TANK OF CO2 AND NOT OXYGEN. PATIENT WAS IMMEDIATLEY CONNECTED TO O2. THE RESUCITATION RESUMED AND NORMAL SINUS RHYTHM RESTORED WITHIN MINUTES. CO2 TANK IS A GREY COLOR WITH FLOW METER LABELED "CARBON DIOXIDE". OXYGEN TANK IS A GREEN COLOR. BOTH HAVE SMALL LABELS FROM MANUFACTURER STATING NAME OF PRODUCT THAT IS VISIBLE FROM ONE SIDE. ONCE THE TANK IS PLACED IN A HOLDER THE LABEL MAY NOT BE VISIBLE.FOLLOW UP REVEALS: THIS PRODUCT WAS USED IN THE OPEN HEART ROOM THAT REQUIRES CO2 AND HAS THE END THAT REQUIRES THE TAPERED SWIVEL CONNECTOR, THAT CAN BE CONNECTED TO THE OXYGEN CONNECTOR. THIS CONNECTOR IS NOT THOUGHT TO HAVE BEEN AN ISSUE IN THIS CASE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 CARBON DIOXIDE TANK CARBON DIOXIDE GAS CYLINDER ECX COYNE * *
    2 M1 SERIES FLOWMETER REGULATOR AND SWIVEL CONNECTORS CO2 REGULATOR CAN WESTERN MEDICAL * *
    3 NUT AND NIPPLE TO TAPERED BARB (GREEN) SWIVEL CONNECTORS BZA WESTERN MEDICAL M24-45P *
    4 NUT AND NIPPLE TO TAPERED BARB (WHITE) SWIVEL CONNECTOR BZA WESTERN MEDICAL M24-45PW *

    Patients

    Seq Age Sex Outcome Treatment
    1 73 YR Required Intervention