Maxtec/Tri-Anim—Dual-Air and Oxygen Hoses: Air and Oxygen DISS Fittings May Be Switched, Potentially Resulting in Higher or Lower than Expected Oxygen Delivery
December 12, 2012 | Risk Management News
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In a November 26, 2012, Product Advisory Notification letter submitted by an ECRI Institute member hospital, Tri-anim states that the air and O2 diameter index safety system (DISS) fittings on the hoses below may have been inadvertently switched at the wrench tighten end. An improperly manufactured hose was found to have an O2 DISS connector on the yellow air hose and an air DISS connector on the green O2 hose. In a November 9, 2012, Advisory Notification letter, Maxtec states that this problem may result in delivery of lower or higher oxygen concentrations than expected during use. The risk of delivering lower or higher oxygen concentrations is relatively low because of the alarms on the majority of ventilators coupled with other clinical controls in place for patient care (e.g., blood gas and O2saturation measurements). The manufacturer and distributor have not...