Pin index safety system and color coding : is it enough ?
Joint Authors
Naithani, Udita
Bitkikar, Sniha Arun
Verma, Divindra
Gehlot, Ravindra K.
Sundararaj, Rajkumar
Source
Ain Shams Journal of Anesthesiology
Issue
Vol. 9, Issue 4 (31 Dec. 2016), pp.626-628, 3 p.
Publisher
Ain Shams University Faculty of Medicine Department of Anesthesiology
Publication Date
2016-12-31
Country of Publication
Egypt
No. of Pages
3
Main Subjects
Topics
Abstract EN
Despite a number of preventive mechanisms, inadvertent administration of nitrous oxide in place of oxygen can lead to fatal hypoxemia.
Here we report two cases of hypoxia that occurred when we switched to the emergency cylinder for oxygen supply after exhaustion of the main oxygen cylinder.
The urgency shown by the anesthetist and operating room staff to restore the main oxygen supply prevented any fatalities from occurring in our case.
We found that there was incorrect painting of the nitrous oxide cylinder with the color code of oxygen.
Further, damaged pins on the yoke assembly allowed the attachment of the faulty E cylinder to the machine.
Even though such errors are made by the supplier we suggest that all equipment including the cylinder be thoroughly checked by the anesthetist.
This also highlights the role of respiratory gas monitoring in the prevention of such mishaps.
American Psychological Association (APA)
Naithani, Udita& Bitkikar, Sniha Arun& Verma, Divindra& Gehlot, Ravindra K.& Sundararaj, Rajkumar. 2016. Pin index safety system and color coding : is it enough ?. Ain Shams Journal of Anesthesiology،Vol. 9, no. 4, pp.626-628.
https://search.emarefa.net/detail/BIM-762555
Modern Language Association (MLA)
Naithani, Udita…[et al.]. Pin index safety system and color coding : is it enough ?. Ain Shams Journal of Anesthesiology Vol. 9, no. 4 (Oct. / Dec. 2016), pp.626-628.
https://search.emarefa.net/detail/BIM-762555
American Medical Association (AMA)
Naithani, Udita& Bitkikar, Sniha Arun& Verma, Divindra& Gehlot, Ravindra K.& Sundararaj, Rajkumar. Pin index safety system and color coding : is it enough ?. Ain Shams Journal of Anesthesiology. 2016. Vol. 9, no. 4, pp.626-628.
https://search.emarefa.net/detail/BIM-762555
Data Type
Journal Articles
Language
English
Notes
Includes bibliographical references : p. 628
Record ID
BIM-762555