Abstract
BackgroundThe pin-index medical gas pipeline system, which complies with Japan Industrial Standard (JIS), is considered to be “foolproof” and is widely used in Japan to avoid medical gas misconnections.Case presentationThe wall-mounted gas outlet used in our hospital (NSV outlet, CENTRAL UNI, Co., Ltd., Tokyo, Japan) contains multiple sockets, which connect to hoses with gas-specific pins. Each socket is covered with a gas-specific plastic pin guide, which is considered to make the system foolproof; i.e., to prevent misconnections. However, while checking an anesthesia machine in accordance with the guidelines developed by the Japanese Society of Anesthesiologists, an anesthesiologist found that one of the gas-specific plastic pin guides covering the wall-mounted gas outlets had disappeared; and hence, the gas outlet system was no longer foolproof. A subsequent verification test performed by engineers of the system’s manufacturer revealed that the plastic pin guides could be dislodged by applying 29.4 N of vertical force.ConclusionsIt is important to check that gas outlet systems are functioning in a gas-specific manner when they are used for clinical purposes.
Highlights
BackgroundMedical gas misconnections can have direct life-threatening effects. safe and secure medical gas supply systems are required to ensure the safety of clinical work
The pin-index medical gas pipeline system, which complies with Japan Industrial Standard (JIS), is considered to be “foolproof” and is widely used in Japan to avoid medical gas misconnections.Case presentation: The wall-mounted gas outlet used in our hospital (NSV outlet, CENTRAL UNI, Co., Ltd., Tokyo, Japan) contains multiple sockets, which connect to hoses with gas-specific pins
It is important to check that gas outlet systems are functioning in a gas-specific manner when they are used for clinical purposes
Summary
Medical gas misconnections can have direct life-threatening effects. safe and secure medical gas supply systems are required to ensure the safety of clinical work. During a morning check of an anesthesia machine in accordance with the guidelines published by the Japanese Society of Anesthesiologists, an anesthesiologist found that a gas-specific plastic pin guide that had been covering a universal gas outlet had disappeared (Fig. 2). Though procedures, such as a color-coding, a sequence of the socket, and a signage, would prevent an anesthesiologist from making an improper connection, a less-experienced medical worker could have connected the wrong pipeline to this outlet. According to our interview to the anesthesiologists and the clinical engineers in our hospital at a later
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
