Accidental gas pipeline mix ups

Hole in mixing valve – this near miss would not have been avoided by a single post installation gas assessment.

Air contamination intraop due to maintenance being performed on lines thought to be not in use

Air contamination of Oxygen pipeline

Please note the cases above would not have been identified by a static gas analysis performed after pipeline installation.

45 gas pipeline deaths reported in US from 1977 to 1992

Closed claims database

Literature review from Indian database 2013

Literature review published in Anaesthesia 2007

Gas pipeline crossover Wesley Hospital Brisbane

Nitrous Oxygen cross over Australia 1983

22 deaths Sudbury Canada 1972

300 patients potentially given nitrous instead of oxygen

2 deaths Connecticut 2002

2 deaths Maharaja Yashwantrao Hospital May 2016

15 month old death India June 2016

German review article – Der Anaesthetist Sept 2008

Several case reports from US in 1990s

Chapter in Anaesthetic Equipment book details frightening scale of the problem

Multiple references of gas misconnections

Slide presentation indicates that despite policies with gas delivery mistakes still happen

France 2001 – 2 cases of nitrous oxide contamination of oxygen one leading to death

4 patient deaths in ICU in India 2014 after Oxygen supply cut off

2 deaths Japan 1987

Central Oxygen Pipeline Failure South Africa

1984 Poitiers France death of 34yr old from O2 N2O switch

Pipeline issue remains undetected for 6 months

2 deaths (perhaps 6 more) Italy 2007

Please note these are only a few of the related articles on the topic discovered from a brief internet search. We’ve little doubt the magnitude of this problem is much greater than represented here.